
Class 



Copyright^ . 



COPYRIGHT DEPOSIT. 



TREATISE 

ON 



FRACTURES 



BY 

JOHN B. ROBERTS, A.M., M.D., F.A.C.S. 

PROFESSOR OF SURGERY IX THE PHILADELPHIA POLYCLINIC AND COLLEGE 

FOR GRADUATES IN MEDICINE; SOMETIME CHAIRMAN OF FRACTURE 

COMMITTEE OF AMERICAN SURGICAL ASSOCIATION; MEMBRE 

DE LA SOCIETE INTERNATIONALE DE CHIRURGIE 



JAMES A. KELLY, A.M., M.D. 

ATTENDING SURGEON TO ST. JOSEPH'S, ST. MARY'S AND ST. TIMOTHY'S 
HOSPITALS; ASSOCIATE IN SURGERY IN THE PHILADELPHIA POLY- 
CLINIC AND COLLEGE FOR GRADUATES IN MEDICINE 



WITH 909 ILLUSTRATIONS: 
RADIOGRAMS, DRAWINGS AND PHOTOGRAPHS 




PHILADELPHIA & LONDON 

B. LIPPIXCOTT COMPANY 



tJ\lo 



Copyright 1916, by J. B. Lippincott Company 







0* 



I 

APR 21 ISI6 



F.leclrotyped and printed by J. B. TJppincott Company 
The Washington Square Press, Philadelphia, U.S. A. 



©CI.A428618 



PREFACE 



The object of this book is to supply student and medical prac- 
titioner with a clear, concise, and systematic presentation of the subject 
of fractures. 

In the following pages, a careful classification of the varieties of 
fracture occurring in each bone is given, together with statistics, symp- 
tomatology, diagnosis, prognosis and treatment. The varieties of frac- 
ture are shown by well-selected radiograms, the displacement of 
fragments is illustrated by accurate drawings, and when possible the 
methods of reduction and the application of retentive apparatus is 
presented by photographs. 

The universal use of the Rontgen ray as a means of accurate 
diagnosis has brought about greater success in the recognition of frac- 
tures and has shown that many received methods of treatment are 
faulty or imperfectly understood. As a result, many fractures have 
been operated upon in which good anatomical and functional results 
could have been obtained by more conservative measures. 

The purpose of the authors is to present a lucid view of the subject 
in the light of recent discoveries, to point out an accurate scientific 
procedure, whether operative or otherwise, according to the character 
of individual injuries and to urge the general practitioner, as well as 
the surgical specialist, to the study of methods, operative or non- 
operative, with augury of propitious result. 

The authors are indebted to Drs. M. B. Miller, J. H. Jopson, G. G. 
Davis, G. P. Muller, J. H. Hutchinson, J. M. Spellissy, L. J. Hammond, 
J. T. Rugh, E. R. Kirby. J. H. Ross, J. A. Boger, A. C. Wood, H. S. 
Carmany, A. Hewson, O. A. Rath, J. Chalmers Da Costa, C. F. Nassau, 
M. M. Franklin, J. F. X. Jones, A. A. Sender, F. C. Hutton, and M. F. 
Percival, for many rontgenograms. 

The photographs of specimens, patients, dressings and copies of 
skiagrams were made by Mr. Meyer S. Lentz, the original drawings 



iv PREFACE 

by Mr. Erwin F. Faber, to both of whom the authors are grateful for 
skill, patience and untiring energy. 

In all instances an endeavor has been made to give proper credit in 
the text and illustrations to the work of other writers. 

Finally they wish to thank the publishers for many helpful sugges- 
tions and active cooperation in the presentation of this volume to the 
medical profession in such an attractive form. 

John B. Roberts 
James A. Kelly 

Philadelphia, 

January, 19 16. 



CONTENTS 

I. General Considerations i 

II. The Operative Treatment of Closed Fractures 85 

III. Fractures of the Cranium 116 

IV. Fractures of the Bones of the Face 172 

V. Fractures of the Malar Bone 180 

VI. Fractures of the Superior Maxilla 185 

VII. Fractures of the Mandible 188 

VIII. Fractures of the Hyoid Bone 205 

IX. Fractures of the Cartilages of the Larynx and Trachea 208 

X. Fractures of the Vertebr.e 212 

XI. Fractures of the Sternum 251 

XII. Fractures of the Ribs and the Costal Cartilages 255 

XIII. Fractures of the Clavicle 264 

XIV. Fractures of the Scapula 278 

XV. Fractures of the Humerus 290 

XVI. Fractures of Radius and Ulna 353 

XVII. Fractures of the Carpal Bones 417 

XVIII. Fractures of the Metacarpal Bones 422 

XIX. Fractures of the Phalanges 431 

XX. Fractures of the Pelvis 435 

XXI. Fractures of the Femur 457 

XXII. Fractures of the Patella 525 

XXIII. Fractures of the Tibia and Fibula 540 

XXIV. Fractures of the Tarsal Bones 599 

XXV. Fractures of the Metatarsal Bones 622 

XXVI. Fractures of the Phalanges of the Foot 629 

XXVII. Fractures of the Small Sesamoid Bones 631 

XXVIII. Birth Fractures 638 

XXIX. Gunshot Fractures 646 



ILLUSTRATIONS 



FIG. PAGE 

1 . Osteomyelitis (typhoid) of femur 9 

2. Sarcoma of right humerus 9 

3. Pathologic fracture of right femur 10 

4. Pathologic fracture of right humerus 10 

5. Types of fractures 12 

6. Fractures considered in relation to the character and line of fracture 13 

7. Fractures considered in relation to the position of the fracture 14 

S. Articular fractures 14 

9. Fractures considered in relation to the number of fragments 15 

10. Varieties of displacement of fragments 16 

11. Rontgenogram showing pseudarthrosis of radius and ulna 26 

12. Pseudarthrosis following open fracture of radius and ulna, operated upon twice 27 

13. Vicious union 28 

14. Rontgenogram showing diacondylar fracture of humerus 29 

15-16. Moist gangrene of hand and part of forearm 30 

17. Ischaemic muscular atrophy 31 

18. The same after operation 31 

19. Isthxmic muscular atrophy 32 

20. The same after operation 32 

21. Epiphyseal lines of upper end of right humerus 40 

22. Epiphyseal lines and centre of lower end of humerus, and upper ends of radius 

and ulna 41 

23. Epiphyseal lines and centres of lower ends of radius, carpal, metacarpal and 

phalyngeal bones of hand 42 

24. Epiphyseal lines of pelvis and upper end of femur 43 

25. Epiphyseal line of crest of ileum 44 

26. Epiphyseal lines and centres of lower end of femur, patella, and upper ends of 

tibia and fibula 45 

27. Epiphyseal lines and centres of lower end of tibia and fibula, and of calcaneum 46 

28. Epiphyseal lines and centres of metatarsal and phalyngeal bones of foot 47 

29. Interference with subsequent growth of the fourth metacarpal following a 

previous epiphyseal separation 50 

30. Method of making moulded gypsum splints 65 

31 . Moulded gypsum shoulder-cap 66 

32-34. Method of using gypsum bandages in treating fracture of the clavicle 66 

35. Gypsum case applied over flannel bandage for fracture of shafts of both bones 

of forearm 67 

36. Moulded gypsum splint for fracture of shaft of radius or of ulna 67 

37. Anterior and posterior gypsum splints for fracture of lower end of radius 67 

38. Method of applying gypsum splints by means of muslin bandage 67 

39. Moulded gypsum splint for fracture of first metacarpal 68 

40. Circular gypsum case for fracture of carpal bones or of first metacarpal 68 

41. Method of holding lower extremity for application of circular gypsum case in 

treatment of fracture of bones of leg 69 

42. Finished gypsum case applied to lower thigh, leg, and foot 69 

43-44. Moulded gypsum splints for fractures about the ankle-joint 70 



viii ILLUSTRATIONS 

Fig. page 

45. Moulded gypsum splint for fracture of the metatarsal bones 71 

46. Method of applying traction to leg and thigh. The Buck's extension apparatus 72 

47. Bardenheuer's method of extension 73 

48. Thos. Bryant's method of vertical traction 74 

49. Oblique traction used for subtrochanteric fracture of femur 74 

50. Steinmann's method of nail extension 75 

51. Steinmann's method of nail extension for fracture of the femur 76 

52. Zuppinger's method of traction and support for fracture of the femur 77 

53. Zuppinger's method of traction and support for fracture of the bones of the leg 78 

54. This figure illustrates the control of the leg in plating fractures, on applying 

gypsum case, using Dr. Hawley's table 90 

55. Flexion and abduction of the thigh in the treatment of subtrochanteric fractures 

of the femur 90 

56. Subject with legs in extreme abduction, the Whitman position for the treatment 

of fracture of the neck of the femur 91 

57. Support and traction of the left arm with counter-traction by a wide sling 

around the body 92 

58. Traction with pulleys and Levis's plate during operative fixation of old femoral 

fracture 92 

59. Fixation with two wire sutures of aluminum opposite planes 93 

60. Low fracture of surgical neck of right humerus 93 

61 . Application of Lane plate in low fracture of surgical neck of right humerus 93 

62-65. Fracture of internal condyle of humerus 94 

66-69. Fractures of middle of shaft of radius and ulna 95 

70-72. Result of operation in case of fracture of shafts of radius and ulna .... 96 

73. Lane's bone plate 97 

74. Subtrochanteric fracture of left femur 98 

75. Lowman's cone clamp for adjusting plate; Pierce's bone screw holder and screw 

driver; Sherman's tap screws 98 

76-77. Spiral fracture of shaft of right femur 99 

78-79. Transverse fracture of shaft of femur 100 

80. Oblique fracture of shaft of left femur; moderate overlapping of fragments 101 

81. Oblique fracture of shaft of left femur; application of Sherman plate 101 

82-820. Photographs of above patient taken after eight weeks 101 

83-84. Separation of lower epiphysis of femur 102 

85-86. Closed fractures of shafts of tibia and fibula 102 

87-88. Communited fractures of tibia and fibula 103 

89-90. Application of Lane plate and screws followed by moderate necrosis of ends 

of fragments 103 

91-92. Lane plate and screws removed, beginning union 104 

93-94. Final results. No shortening, good function 104 

95-96. Oblique fractures of shafts of tibia and fibula 105 

97-98. Application of Lane plate and screws to tibia 105 

99-100. Final result in fracture of tibia and fibula after application of Lane plate 

and screws 106 

101-102. Open oblique fractures of tibia and fibula 107 

103-104. Result obtained after reduction and immobilization in gypsum case 108 

105-106. Osteotomy for malunion 108 

107-108. Closed fracture of shaft of the tibia, followed by an acute suppurative 

osteomyelitis 109 

109-110. Photographs of Figs. 107 and 108 showing shortening, deformity and 

muscular atrophy no 



ILLUSTRATIONS 



IX 



FIG. PAGE 

in. (a) Albee's electric twin saw used in removing transplant from tibia and for 

cutting groove in the fractured bone; (b) Albee's dowel cutter in 

112. Albee's method of inlay bone graft for fixation of fractures 112 

1 13-1 14. Open ununited fractures of tibia and fibula 113 

115-116. Inlay bone graft in place in tibia 113 

117. Front view of skull 117 

118. Lateral view of skull 1 1 8 

1 19. Craniocerebral localization 119 

120. The inner surface of the base of the skull 120 

121. Calvarium; transverse fracture of the vault 122 

122. Skull. Fracture of the base 122 

123. Skull without calvarium; fracture of the right temporal and parietal bones. . . 122 

124. Rontgenogram showing fissured fracture of cranium 123 

125. Fissured fracture of vault of skull, occipital region 123 

126. Comminuted fracture of skull, frontal region 124 

127. Skull; lower half; fracture of the base 124 

128. Skull; extensive fracture involving the right parietal, frontal, temporal, oc- 

cipital and sphenoid bones 124 

129-130. Calvaria. Fracture of the right parietal bone 125 

131-132. Fracture of skull left parietal region — epidural hemorrhage 126 

133. Skull; fracture of the superior angle of the occipital bone with fracture of both 

temporal bones in horizontal line separating the squamous from the mastoid 
portions and passing through the auditory canals 127 

134. Rontgenogram showing depressed comminuted fracture of skull, parietal region 128 

135. a and b. Calvarium; fracture of the right parietal, compound comminuted, and 

depressed 128 

136. Calvarium; depression of the right parietal 129 

137. Calvarium: depressed fracture of the left parietal bone 5.5 cm. long in the 

left parietal bone parallel to the interparietal suture 129 

138. Anterior half of calvarium. Punctured fracture at three points with depression 

of the internal table 129 

139. Calvarium; fracture of left frontal and both parietals 129 

140. Diagrammatic illustration showing effects of a perforating bullet wound of skull 

and brain 1 30 

141. Gunshot wounds of head with fractures of skull 131 

142. Base of brain case with two probes indicating direction of bullets 131 

143. Fracture of the base of the skull by transmitted force applied to the lower jaw 133 

144. Line of fracture of base, from force applied to the median frontal region 135 

145. Line of fracture of base, from force applied to the lateral frontal region 135 

146. Lines of fracture of base, from force applied in the region of the external ear. 136 

147. Line of fracture of base, from force applied in the region of the mastoid 136 

148. Line of fracture of base, from force applied to the lateral occipital region .... 137 

149. Lines of fracture of the base from force applied to the posterior occipital region 137 

150. Fracture of the base with laceration of the carotid arteries 140 

151. Fracture of the base with laceration of the cavernous sinus 140 

152. Shows position of cranial nerves and their liability to laceration in various 

fractures at the base of the skull 143 

133. Cerebral pressure from an extradural clot from hemorrhage from the posterior 

branch of the middle meningeal artery 1 43 

1 54. Kronlein 's method for points of election for trephining in meningeal hemorrhage 1 45 
I 55- Temperature chart showing primary shock in fracture of base with subsequent 

rise to normal 149 



x ILLUSTRATIONS 

FIG. PAGE 

1 56. Temperature chart showing primary shock in fracture of base with subsequent 

rise and later return to norma! 1 50 

157. Temperature chart showing rapid and progressive rise of temperature in 

fracture of the base followed by death fourteen hours after admission 151 

158. Chart showing moderate elevation of temperature which remains stationary 

followed by recovery 151 

159. Temperature chart showing moderate rise followed by fall to below normal, 

ending fatally 1 52 

160. Temperature chart in a case of fracture of the base and marked laceration of 

the brain, showing variable temperature changes ending in ultimate recovery 153 

161. Method of trephining with the Hudson instruments. After exposure of the 

site of the fracture the skull may be opened at the site of depression 163 

162. Hudson's trephine bits, showing the use of the spiral perforator, the spiral 

follower and the enlarging burr 163 

163. Removing a button of bone at the edge of the depressed fracture by means 

of the hand trephine 164 

164. Elevating depressed fragment of bone after trephine opening has been made ... 164. 

165. Showing method of exposure of anterior and posterior branches of the middle 

meningeal artery at the points of election 165 

166. Showing method of enlarging trephining openings at points of election to 

reach the anterior and posterior branches of the middle meningeal artery. . 167 

167. Trephine opening for subdural hemorrhage 16S 

168. Enlargement of trephine opening with rongeur forceps, and incision of dura. . 168 

169. After washing out subdural clot a rubber-tube drain is inserted and the dura 

closed by interrupted sutures about the drain. The end of the latter is 
carried through the temporal fascia and skin 169 

170. Shows suture of the temporal muscle by interrupted sutures of catgut, and 

partial closure of the temporal fascia 169 

171. Diagram of side of nose showing relations of bones and cartilages 172 

172. Diagram of the bones and cartilages of the nose, anterior view 172 

173. Diagram of the septum of the nose 1 72 

174. (a) Fracture of nasal bones and nasal process of left maxilla 173 

(b) Fracture of nasal bones and nasal process of right maxilla 173 

(c) Fracture and dislocation of nasal bones 173 

I75 -I 76- Showing depressed healed fractures of right frontal, malar, superior 

maxilla and nasal bones 173 

177. Showing fracture of nasal bones with depression of fragments 174 

178. Skull; old fracture of nasal bones and left zygoma 175 

179. Skull; fracture of the nasal bones; union 175 

180. Mosher's method of reducing, with thumb and elevator, fracture dislocation of 

nasal bones 177 

181. Diagram of septal lesions due to blow in front 178 

182. Robert's use of pins to hold fragments of fractured septal cartilage in cor- 

rected posi tion 178 

183. Method of palpation of malar bones 181 

184. Lower half of skull. Fracture of the left malar; union 181 

185. Skull; old fracture of the nasal and left malar bones 181 

186. Skull; fracture of left malar 182 

187. Lothrop's method of reduction of depressed and comminuted fractures of the 

malar and superior maxilla 183 

1 83. Matas's method of reduction of a depressed fracture of the zygomatic arch . 183 



ILLUSTRATIONS xi 

FIG. PAGE 

189. Mandible, outer aspect 188 

190. Fracture of mandible through symphysis 189 

191. Mandible; old fracture of the body; union 190 

192. Fracture of mandible, through mental foramen 191 

j 93. Inferior maxilla; ununited fracture 192 

194. Fracture of mandible through body 193 

195. Fracture of mandible, malar region, showing type of displacement of frag- 

ments 193 

196. Fracture of mandible through angle 194 

197. Fracture of mandible through malar region showing type of displacement of 

fragments 195 

198. Infeiror maxilla; oblique fracture of the ramus 195 

199. Fracture of mandible through neck of condyle 196 

200. Condyloid process "bent" in and forward to almost a right angle with the 

ramus 197 

201. Posterior view of mandible showing a united fracture of neck of left condyle 197 

202. An anterior view of the same skull 198 

203. Fracture of mandible through base of anterior part of alveolar process 198 

204. Method of determining crepitus and abnormal mobility of fragments in frac- 

ture of the mandible 199 

205. Moulded felt chin splint padded with several layers of sheet-wadding 200 

206. Application of occipitomental roller bandage to hold chin splint in place in 

fracture of the mandible 200 

207. A fracture of the mandible showing interdental splint in position 201 

208. An interdental splint holding the mandible together where a pathological sepa- 

ration of bone occurred, causing the loss of a complete section of bone 201 

209. An interdental splint used in case of a compound fracture of the mandible. . . 202 

210. Two compound fractures at the angles of the mandible treated by a mandi- 

bullomaxillary splint 202 

211. Rontgenogram showing method of suture of fragments of the mandible with 

silver wire 203 

212. The hyoid bone, anterior view 205 

213. Fracture of the hyoid bone 206 

214. Adult spine, lateral view 213 

215-216. Method of palpation through the mouth of the anterior surface of the 

bodies of the upper cervical vertebras 214 

217. Method of palpation of the coccyx through the anus 215 

218. Compression fracture of the body of the first dorsal vertebra 216 

219. Fracture-dislocation of the fourth and fifth dorsal vertebras 216 

220. Last three dorsal and first lumbar vertebras. Fracture of the body of the 

twelfth dorsal 217 

221. Ninth, tenth, eleventh and twelfth dorsal, and first two lumbar vertebrae. 

Fracture of the last dorsal 217 

222. Eleventh and twelfth dorsal and first lumbar vertebras. Vertical fracture of 

the twelfth dorsal and crescentic fracture of the upper and anterior lip of the 

first lumbar 217 

223. Old compression fracture of bodies of second, third and fourth cervical vertebrae 2 1 8 

224. Fracture of body of fifth cervical vertebra 219 

225. Diagram to show types of isolated fracture of the arches, spinous and trans- 

verse processes of the vertebras 220 



xii ILLUSTRATIONS 

FIG. PAGE 

226. Six lower cervical vertebrae. Fracture of the left lamina and pedicle of the 

fourth and of the laminae of the fifth cervical vertebrae 220 

227. Compression fracture of fourth and fifth cervical vertebrae 220 

228. Fracture of lateral processes of the fifth and sixth cervical vertebras, left side 220 

229. Dislocation forward of sixth cervical vertebrae 221 

230. The lower dorsal and four upper lumbar vertebrae with portions of the three 

lower ribs of both sides 222 

231. Cervical vertebrae; luxation of the atlas 222 

232. Fracture-dislocation of fourth cervical vertebra 223 

233. Fracture-dislocation of bodies of eighth and ninth vertebrae 224 

234. The relation of the segments of the spinal cord and their nerve- roots to the 

bodies and spines of the vertebrae 226 

235. Position in lesion of spine between the fifth and sixth cervical vertebrae 228 

236. Position in luxation of the sixth and seventh cervical vertebrae 228 

237. Anaesthesia resulting from a lesion of the fifth cervical segment 229 

238. Area of anaesthesia in a lesion involving the sixth cervical segment on the right 

and the fifth cervical segment on the left 229 

239. Anaesthesia produced by a lesion of the seventh cervical segment 230 

240. Anaesthesia produced by a lesion of the first dorsal segment 230 

241. Areas of anaesthesia in fracture of the spine involving the sixth and seventh 

cervical vertebrae 231 

242. Right-sided anaesthesia due to lesion of the fifth cervical segment and left- 

sided anaesthesia due to a lesion of the first dorsal segment 231 

243-244. Anaesthesia produced by a lesion of the eleventh dorsal segment. An- 
terior and posterior views 232 

245. Area of anaesthesia following injury to the seventh dorsal segment 233 

246-247. Area of anaesthesia produced by a lesion of the lower two lumbar seg- 
ments on the left side and of the entire lumbar segment of the right side, 

anterior and posterior views 234 

248-249. Anaesthesia following a lesion of the fifth lumbar segment 235 

250. Anaesthesia following a lesion of the fifth sacral segment 236 

251-252. Show area of anaesthesia in fracture involving the fourth lumbar segment 237 

253. Anaesthesia following a lesion of the second sacral segment 238 

254. Anaesthesia following a lesion of the third sacral segment 238 

255. Anaesthesia following a lesion of the fourth sacral segment 239 

256. Anaesthesia due to compression of the cauda equina 239 

257. Showing deformity in compression fracture of the body of the second lumbar 

vertebra 249 

258-259. Showing use of spinal convalescent brace for fracture of vertebrae 249 

260-261. Showing use of convalescent brace in the treatment of fractures of cervical 

vertebrae 250 

262. Sternum, anterior view 252 

263. Sternum, transverse fracture of, union 253 

264. Sternum, oblique fracture of; union 253 

265. Showing type of displacement usual in fractures of the sternum 254 

266 Left rib; fracture; union 257 

267. Rdntgenogram of healed fractures of the fourth to ninth left ribs 258 

268. Showing relation of intercostal artery, vein and nerve to the rib 259 

269. Method of making alternate pressure over rib near seat of fracture to determine 

abnormal mobility and pain 259 

270. Method of making anteroposterior compression of the chest-wall 259 

271. Compression injury of chest 260 



ILLUSTRATIONS xiii 

FIG. PAGE 

272. Cross-section of chest, showing normal relations of intrathoracic structures 

to the overlying ribs 260 

273. Diagrammatic representation of complications in fracture of the ribs 260 

274-275. Method of application of the adhesive plaster swathe in the treatment of 

fractures of the ribs 261 

276. Right clavicle, upper surface 264 

277. Palpation of clavicle, method of determining crepitus, abnormal mobility 

and deformity 265 

278. Fracture of the middle third of the clavicle, direct violence 266 

279. Fracture of the middle third of the clavicle by indirect violence, characteristic 

deformity 267 

280. Fracture of the clavicle, junction of the middle and inner thirds 268 

281. Fracture of middle third of clavicle, absence of displacement of fragments 

produced by indirect violence 268 

282. Shows typical displacement of fragments in complete fracture of middle third 

of clavicle 269 

283. Drawing to demonstrate typical displacement of fragments in fracture of 

middle third of clavicle 269 

284. Fracture of outer end of clavicle 270 

285. Fracture of tip of outer end of clavicle 271 

286. Fracture of the outer end of the clavicle 271 

287. Showing the attachments of the coracoclavicular and coraco-acromial liga- 

ments and the reason for absence of displacement in fractures of the outer 
end of the clavicle 272 

288. Fracture of the inner end of the clavicle 273 

289-292. Method of applying Sayre dressing for fracture of the clavicle 274 

293. Finished Sayre dressing for fracture of the clavicle 275 

294-295. Application of claviculo-humeral bandage in fracture of the clavicle 

unattented by any great degree of deformity 276 

296-297. Stimson's" figure-of-eight "dressing for fracture of the acromial end of the 

clavicle 277 

298. Right scapula, anterior view 279 

299. Method of palpation for suspected fracture of scapula 280 

300. Method of palpation of coracoid processes of the scapulae 280 

301. Left scapula; stellate fracture of the superior angle 280 

302. Fracture through spine of scapula 281 

303. Right scapula; comminuted fracture of the base of the acromion process; union 281 

304. Fracture through base of acromial process of scapula 282 

305. Sprain-fracture of acromial process of scapula 283 

306. Separation of the epiphysis of the acromial process of the scapula 283 

307. Method of determining abnormal mobility and crepitus in fracture of the 

acromial process of the scapula by forced hyperabduction of the arm 284 

308. Dressing to immobilize shoulder in fracture of scapula 285 

309. Fracture of the surgical neck of the scapula 286 

310. Displacement of fragments in fracture through the neck of the scapula 287 

311. Method of determining crepitus and abnormal mobility in fracture of the 

neck of the scapula by forced elevation of the shoulder 287 

312. Tear-fracture of epiphysis of coracoid process of scapula 288 

313. Right humerus, front view 291 

314. Upper end of humerus showing cupping of epiphysis to receive the pointed 

head of the diaphysis 292 

315. Rontgenogram of normal shoulder-joint 292 



xiv ILLUSTRATIONS 

FIG. PAGE 

316. Rontgenogram showing normal epiphysis of upper end of humerus 292 

317. Method of determining crepitus and abnormal mobility in fracture of the 

upper end of the humerus 293 

318. Method of determining crepitus and abnormal mobility in fracture of the 

shaft of the humerus 293 

319. Method of palpation of the condyles of the humerus 293 

320. Showing the normal relation of the olecranon process of the ulna and of the 

condyles of the humerus in full extension of the elbow 293 

321 . Palpation of the head of the radius 294 

322. The carrying angle; formed by the deviation of the axis of the forearm from 

the humeral axis 294 

323. Incomplete fracture of the head of the humerus 295 

324. Fracture of the anatomical neck of the humerus, with dislocation of the head 

into the axilla 295 

325. Fracture of the humerus through the greater tuberosity, with dislocation of 

the head into the axilla 297 

326. Fracture of the humerus through the tuberosities 297 

327. Fracture of the greater tuberosity and of the surgical neck of the humerus. . . 298 

328. Humerus, right; fracture of the greater tuberosity 299 

329. Usual character of epiphyseal separation 302 

330. Separation of upper epiphysis of humerus 302 

331. Separation of upper epiphysis of humerus 303 

332. (Same as Fig. 331. after reduction.) 303 

333~335- Photographs of case (Figs. 331 and 332) of separation of upper epiphysis 

of left humerus 304 

336. Oblique fracture of surgical neck of left humerus 305 

337. Comminuted fracture of surgical neck of right humerus 305 

338. Humerus, left; fracture of the surgical neck. Union 306 

339. Method of determining shortening in fracture of the humerus 306 

340. Fracture of humerus through surgical neck 307 

341. Drawing to show the displacement of fragments in case Fig. 340 307 

342. Method of reduction of fragments in fracture of the surgical neck of the 

humerus by traction and manipulation 308 

343. Dressing for fracture of the surgical neck of humerus 309 

344. Shows completed dressing for fracture of the surgical neck of the humerus. . . 309 

345. Spiral fracture of shaft of humerus 310 

346. Irregular transverse fracture of the shaft of the humerus 310 

347. Transverse fracture of middle of shaft of humerus 310 

348. Oblique fracture of shaft of humerus with over-riding and angular deformity. 310 

349. Long oblique fracture of shaft of humerus 311 

350. Transverse fracture of the shaft of the humerus 312 

351. Drawing made from Fig. 350 to demonstrate the action of the muscles 312 

352. Rontgenogram of oblique fracture of the shaft of the humerus in the region of 

the musculospiral nerve 314 

353. Drawing to show operation for musculospiral paralysis occurring as a compli- 

cation of fracture of the shaft of the humerus 315 

354-356. Method of applying dressing for fracture of shaft of humerus 317 

357-358. Rontgenograms of normal adult elbow region 320 

359-360. Rontgenograms of normal elbow region in child aged 11 yeais 320 

361. Supracondylar fracture of humerus 321 

362. Supracondylar fracture of humerus, extension type 321 

363-364. Supracondylar fracture of humerus 321 



ILLUSTRATIONS xv 

FIG. TAGE 

365-366. Low fracture of the shaft of the humerus 322 

367. Diacondylar fracture of humerus with marked lateral and posterior displace- 

ment of lower fragment 325 

368. Diacondylar fracture of humerus with little displacement of fragments 325 

369. Oblique diacondylar fracture of humerus, with line of fracture running down- 

ward and outward (adduction type) 325 

370. Oblique diacondylar fracture of humerus, with line of fracture running down- 

ward and inward 325 

371. Diacondylar fracture of humerus, " Posadas type," with dislocation of head of 

radius 326 

372. Diacondylar fracture of humerus, " Posadas type" 326 

375-374. Intercondylar T- or Y-fractures of lower end of humerus 327 

375. Intercondylar atypical fracture of lower end of humerus 327 

376-377. Separation of lower epiphysis of humerus. Anteroposterior and lateral 

views 329 

378-379. .Separation of lower epiphysis of humerus, with small fragment of diaphy- 

sis attached 329 

380-381. Fractures of external epicondyle of humerus 330 

382-383. Fracture of external condyle of humerus. Anteroposterior and lateral 

views 331 

384-385. Fracture of external condyle of humerus, fall upon hand with arm ex- 
tended. Anteroposterior and lateral views 332 

386-387. Separation of the epiphyses of the capitellum of the humerus 333 

388-389. Fracture of the internal epicondyle of the humerus 334 

390. Fracture of the internal epicondyle of humerus. Marked downward and for- 

ward displacement of the epicondyle 335 

391. Fracture of the internal epicondyle of the humerus without displacement of 

the fragments 335 

392-393. Tear-fractures of the internal condyle of the humerus 336 

394. Fracture of the internal condyle of the humerus 336 

395-397. Fracture of the capitellum 337 

398. Diacondylar fracture of the humerus 342 

399. Effect hyperflexion has in maintaining reduction of fragments 343 

400. Method of reduction of fractures of the lower end of the humerus 344 

401-402. Old fracture of external condyle of humerus, untreated 345 

403-404. Right cubitus valgus. Old fracture of external condyle of humerus. Un- 
treated 346 

405-406. Old fracture of internal condyle of humerus 347 

407-408. Right cubitus varus. Old fracture of internal condyle of humerus 348 

409. Method of maintaining hj-perflexion of elbow by adhesive plaster strip 349 

410. Rubber tubing sling. Finished dressing in position of hyperflexion 349 

411. Right radius; flexor surface 354 

412. Right ulna; outer surface 354 

413. Lower portion of left humerus with radius and ulna. Incomplete double frac- 

ture of the radius and ulna 355 

414-415 Fracture of shafts of radius and ulna 356 

416-417. Multiple incomplete fractures of shafts of radius and ulna 357 

418. Fracture of shafts of radius and ulna 358 

419. Complete fracture of shafts of radius and incomplete fracture of ulna 358 

420. Drawing to show the usual displacement of fragments in fractures of the shafts 

of the radius and ulna 359 

421. Bone of right upper extremity; union with co-ossification 360 



xvi ILLUSTRATIONS 

FIG. PAGE 

422. Method of dressing with well-padded anterior angular splint, with forearm at 

right angle to arm and in full supination. 362 

423-424. Application of padded right-angle anterior splint and posterior splint for 

fracture of shafts of radius and ulna 362 

425. Showing areas of pressure necrosis from poorly padded anterior and posterior 

splints applied too tightly 363 

426. Posterior deformity from green-stick fracture of shafts of radius and ulna 

before reduction 363 

427. Tear-fracture of the tip of the olecranon process by muscular action 364 

42S. Fracture of olecranon exostosis from direct pull upon flexed elbow 364 

429. Incomplete fracture of base of olecranon process. Direct violence 365 

430. Comminuted fracture of olecranon. Direct violence 365 

43 1 . Transverse fracture of olecranon process. Muscular action. Very little separa- 

tion of fragments 366 

432. Transverse fracture of olecranon process. Marked separation of fragments. . 366 

433. Showing the action of the triceps muscle in causing separation of fragments in 

fracture of the olecranon process 367 

434~435- Slight deformity after incomplete fracture at base of olecranon process . 368 
43 6 ~437- Straight splint applied to internal surface of arm and flexor surface of fore- 
arm for fracture of the olecranon process 369 

438. Application of the internal right-angle splint for fracture of the olecranon proc- 

ess when there is no separation of fragments 369 

439. Method of suture in fracture of the olecranon process attended by separation 

of fragments 370 

440. Fracture of coronoid process of ulna 371 

441. Fracture of the coronoid process of the ulna, complicating a posterior disloca- 

tion of radius and ulna previously reduced 371 

442. Fracture of coronoid process of ulna 372 

443. Fracture of coronoid process of ulna complicating a fracture of the olecranon 

process 372 

444. Fracture of base of coronoid process of ulna complicating a diacondylar frac- 

ture of the humerus 372 

445. Fracture of shaft of ulna, upper third 373 

446. Fracture of shaft of ulna, lower third 373 

447. Fracture of shaft of ulna, middle third 374 

448. Multiple fracture of shaft of ulna, lower third 374 

449. Showing type of displacement in fracture of the shaft of the ulna from direct 

violence 376 

450. Fracture of the head of the radius. No displacement of fragments 377 

451. Fracture of the head of the radius; slight displacement of fragment; compli- 

cated by fracture of coronoid process of the ulna 377 

452. Fracture of head of radius. Moderate displacement of the fragment 378 

453. Fracture of the head of the radius complicating posterior luxation of radius 

and ulna which had been reduced 378 

454. Posterior luxation of the radius and of the ulna 379 

455-456. Posterior luxation of the radius and ulna 380 

457. Fracture of the upper radial epiphysis 380 

458. Fracture of the neck of the radius with marked displacement of fragments. . 381 

459. Fracture of the neck of the radius 381 

460. Fracture of the shaft of the radius, upper third 383 

461. Fracture of the shaft of the radius, junction of middle and upper thirds 384 

462. Fracture of the shaft of the radius, middle third 384 



ILLUSTRATIONS xvii 

FIG. PAGE 

463. Fracture of the shaft of the radius, lower third 384 

464. Drawing to show the effect of the triceps muscle in causing displacement of 

the upper fragment in fracture of the upper third of the shaft 384 

465. Drawing to show the action of the pronator quadratus muscle in producing dis- 

placement of the lower fragment in fracture of the lower third of the radius 385 

466. Low transverse fracture of radius and ulna 388 

467. Low transverse fracture of radius and ulna. Marked displacement of lower 

fragments 388 

468. Fracture of the tip of the styloid process of the radius 389 

469. Fracture of the base of the styloid process of the radius 389 

470. Fracture of the base of the styloid of the radius and of the styloid of the ulna. . 389 

47 1 . Separation of lower epiphysis of radius with fracture of outer part of the dia- 

physis 389 

472. Irregular transverse fracture of lower end of radius 390 

473. Transverse fracture of lower end of radius with impaction of fragments and 

posterior displacement of the lower fragment 391 

474 . Transverse fracture of the lower end of the radius with outward and posterior 

displacement of the lower fragment 391 

475. Old united Colles' fracture with ununited fracture of styloid process of ulna . . 392 

476. Atypical type of fracture of lower end of radius 392 

477. Healed fracture of lower end of radius 392 

478. Type of so-called reversed Colles' fracture 393 

479. Fracture of the lower end of the radius with anterior displacement of the carpal 

fragment 394 

480. Separation of lower radial epiphysis with posterior displacement of epiphysis. 

and a small fragment of the diaphysis 394 

48 1 . Separation of lower radial epiphysis and fracture of the anterior portion of the 

lower edge of the diaphysis, with anterior displacement cf the lower fragment 394 

482. Separation of lower radial epiphysis with posterior displacement of the lower 

fragment 394 

483. Separation of the lower radial epiphysis with outward and posterior displace- 

ment of the epiphysis 396 

484. Fracture through the carpal articular surface with separation of the posterior 

articular edge 396 

485. Fracture through the carpal articular surface with separation of the posterior 

articular edge 396 

486. Fracture through the carpal articular surface with separation of the anterior 

articular edge 397 

487. Incomplete (green-stick) fracture of the lower end of the radius 398 

488. Incomplete (green-stick) fracture of the lower end of the radius, with fracture 

of the styloid of the ulna 399 

489-493. Types of longitudinal fissure fracture of the lower end of the radius 399 

494. Isolated oblique fracture of the lower end of the radius, with the line of fracture 

running downward and outward 400 

495. Isolated oblique fracture of the lower end of the radius with the line of frac- 

ture running downward and inward 401 

496. Isolated oblique fracture cf the lower end of the radius with the line of fracture 

running downward and inward; also a fracture of the lower third of the ulna 401 

497-498. Types of sprain-fracture of the lower end of the radius 402 

499. Chauffeur's fracture. Line of fracture is at base of styloid process. No dis- 
placement of fragments 403 



xviii ILLUSTRATIONS 

FIG. PAGE 

500. Chauffeur's fracture. Line of fracture is transverse at lower end of radius; also 

involves styloid of radius; also a fracture of styloid of ulna 403 

501. Chauffeur's fracture by muscular action 403 

502. Unreduced Colles's fracture, 7 weeks old 4°4 

5°3-504- Old fracture of radius (Colles's type) and of styloid process of ulna with 

rupture of radio-ulnar ligaments 404 

505. Deformity which may occur in fracture of the lower end of radius and ulna. . . 405 

506. Method of palpation to determine the relative positions of the styloid proc- 

esses of the radius and of the ulna 405 

507. Diagrammatic drawing to show the various lesions with their deformities that 

may occur about the wrist-joint 406 

508. Method of breaking of impaction of classic fracture at the lower end of the 

radius by increasing the deformity 409 

509. Method of reduction of classic fracture at the lower end of the radius by for- 

cible carrying forward of the lower fragment with adduction of the hand. . 409 

510. Morton's method of reducing Colles's fracture by sudden snapping of the lower 

fragment forward 409 

51 1-512. Show application of posterior padded straight splint for immobilization of 

fracture at the lower end of the radius 410 

513. Demonstrating the plane of the posterior aspect of the bones of the forearm 

and hand 411 

514. Method of application of anterior and posterior padded splints for fracture at 

the lower end of the radius 411 

5i5-5!7- Method of application of the anterior and posterior padded abduction 

splint 412 

518-519. Use of the Levis metal splint in the treatment of fractures at the lower 

end of the radius 413 

520. Anterior view of the bones of the carpus and the metacarpus 417 

521. Comminuted fracture of the carpal scaphoid 419 

522. Fracture of the carpal scaphoid 419 

523-524. Sprain-fracture of the tubercle of the carpal scaphoid 420 

525. Fracture of the carpal scaphoid with backward luxation of the radial frag- 

ment which was removed at operation 420 

526. Fracture of the carpal semilunar, direct violence 420 

527. Transverse fracture of first metacarpal at junction of base and the shaft . . 422 

528. Oblique fracture of the shaft of the first metacarpal 422 

529-531. Oblique fractures of the base of the first metacarpal involving the articu- 
lar surface 423 

53 2_ 533- Separation of the epiphysis of the first metacarpal with a fracture of a 

portion of the diaphysis 424 

534. Separation of the epiphysis of the second metacarpal 424 

535. Transverse fracture of shaft of fourth metacarpal 424 

536. Fractures of shafts of second, fourth and fifth metacarpals 425 

537. Comminuted fracture of the base of the fifth metacarpal 425 

538. Arrest of growth of fourth metacarpal following previous separation of its 

epiphyses 425 

539. Method of determining crepitus and mobility of fragments in fracture of the 

metacarpals 426 

540-542. Method of application of padded gutter aluminum splint for fractures of 

the first metacarpal 427 

543-545- Method of application of padded posterior wood splint for fractures of 

the second to the fifth metacarpals 428 



ILLUSTRATIONS xix 

FIG. PAGE 

546-548. Method of application of padded palmar splint for fracture of the second 
to fifth metacarpals, when a tendency to recurrence of deformity is not 
present 429 

549. Transverse fracture of proximal phalanx of thumb 432 

550. Comminuted fracture of proximal phalanx of fifth finger 432 

551. Articular fracture of base of middle phalanx of third finger. " Base-ball " finger 432 

552. Articular fracture of head of middle phalanx of thumb. "Base-ball" thumb. . 432 

553. Separation of epiphysis of proximal phalanx of ring finger 433 

554-55°- Method of application of padded aluminum splint for fractures of pha- 
langes of index finger 433 

557-559. Method of application of padded aluminum splint for fractures of pha- 
langes of fingers 434 

560. Right innominate bone, outer aspect 436 

561 . Male pelvis, anterior view 437 

562-564. Fractures of pelvis 438 

565. Pelvis with fourth and fifth lumbar vertebrae 440 

566. Fracture of the pelvis 441 

567. Pelvis; fracture of the sacrum and left innominate 442 

568. Fracture of the floor of the acetabulum with central dislocation of the head 

of the right femur 442 

569-57 1 . Photographs of case of fracture of the floor of the acetabulum 443 

57 2_ 573- Fractures of the pelvis 444, 445 

574. Portion of left innominate bone 446 

575. Right innominate 446 

576. Irregular fracture of ala of ilium 446 

577. Fracture of the anterior superior spine of the ilium 447 

578. Normal epiphysial line of the crest of the ilium 448 

579. Left innominate; old fracture; exostosis 449 

580. Method of measuring the distance from the median line of the abdomen to 

both trochanters 450 

581. Method of lateral compression to determine crepitus and mobility in sus- 

pected fracture of the pelvis 450 

582. Method of determining crepitus and mobility in suspected fracture of the rim of 

the acetabulum or in Malgaigne's double fracture of the pelvis 450 

583. Drawing to show rupture of the bladder and urethra complicating fracture of 

the pelvis 453 

584. Application of circular adhesive plaster swathe in fracture of the pelvis. . . .456 

585. Completed adhesive plaster swathe for fracture of the pelvis 456 

586. Right femur, anterior view 458 

587. View of outer surface of the bones of the hip showing Roser-Nelaton line 459 

588. Outer surface of right hip and thigh showing Roser-Nelaton line and Bryant's 

triangle 460 

589. Measurements from the anterior superior spine of the ilium to the internal 

malleolus to determine shortening on the injured side 460 

590. Elevation of the great trochanter in fracture of the neck of the femur 461 

591. Relaxation of the fascia lata which occurs in fracture of the femur 461 

592. Method of measuring from the anterior superior spine of the ilium to the in- 

ternal malleolus 463 

593. Showing the shortening which occurs in fracture of the neck or of the shaft of 

the femur as compared with the well side 463 

594. Portions of femoral head 464 

595. Femur: intracapsular fracture of the neck 465 



xx ILLUSTRATIONS 

FIG. PAGE 

596. Femur, right; fracture of the base of the neck 465 

597. Femur, upper third of; intracapsular fracture of the neck 465 

598-605. Fractures of the neck of the femur 466, 467, 468, 469 

606. Showing method of determining false motion in fractures of the neck of the 

femur 47° 

607. Showing why the arc of rotation is shortened, in unimpacted fractures of the 

neck of the femur 471 

608. Anterior luxation of the right hip-joint 477 

609. Method of applying Buck's traction apparatus 477 

610. Principles to be considered in Whitman's abduction method for the treatment 

of fractures of the neck of the femur 478 

61 1. The elevation of the head of the bed 479 

612. The plaster spica holding the limb at the limit of normal abduction 480 

613. Application of plaster-of- Paris case 480 

614-617. Fractures of the femur through the trochanters 484 

618-619. Fractures of the great trochanter of the femur 485 

620. Drawing to show the type of displacement which occurs in fracture of the great 

trochanter 486 

621-622. Subtrochanteric fractures of the femur 488 

623. Modified Zuppinger's apparatus for treatment of fractures in the subtro- 
chanteric region 489 

624-626. Types of fracture of the upper third of the shaft of the femur 493 

627-629. Types of fracture of the middle of the shaft of the femur 491 

630-633. Types of fracture of the lower third of the shaft of the femur 492 

634-638. Types of fracture of the shaft of the femur occurring during child- 
hood 493 

639. Method of determining abnormal mobility and crepitus in fracture of the shaft 

of the femur 496 

640. Femur; fracture through trochanters 497 

641 . Femur, right; fracture of the upper shaft 497 

642. Femur, right; fracture of the neck, trochanter major and shaft; recent 497 

643. Femur, right; transverse fracture of middle shaft 497 

644. Femur, left; fracture of the middle shaft 498 

645. Femur, left; fracture of the lower shaft; union with deformity 498 

646. Femur; fracture of the shaft, junction of the middle and lower thirds 498 

647. Drawing to show type of displacement which may occur in fractures of the 

upper third of the shaft of the femur 499 

648. Fracture of the middle of the shaft of the femur in childhood 500 

649. Drawing to show the action of the thigh muscles in causing displacement of 

fragments 500 

650. Method of applying Buck's traction apparatus 503 

651. Second stage of the modified Buck's traction apparatus 504 

652. The dressing completed 504 

653-655. Vertical extension for the treatment of fractures of the femur in children 507 
656-657. Method of vertical extension by Bryant's method for fracture of the 

shaft of the femur 508 

658. Christen's suspension method for treatment of fractures of the shaft of thefemur 

in children 509 

659. Convalescent splint to be used in the treatment of fractures of the femur. ... 510 

660. Supracondylar fracture of the femur 511 

661. Drawing to show the pull exerted by the gastrocnemius muscle in producing 

posterior displacement of upper end of lower fragment 51 1 



ILLUSTRATIONS 



xxi 



FIG - PAGE 

662-663. Comminuted supracondylar fractures of the femur 512 

664. Supracondylar fracture of the femur 512 

665. Comminuted supra-intracondylar fracture of the femur. Anteroposterior 

view 5 j 2 

666. Comminuted supra-intracondylar fracture of the femur. Lateral view 513 

667. Supracondylar fracture of the femur in a child aged three years 513 

668. Femur, right; fracture of the lower shaft 5^ 

669. Femur, left; comminuted intercondylar fracture 514 

670-67 1. Fracture of internal condyle of femur. Anteroposterior and lateral views 515 

672. Separation of the lower femoral epiphysis. Lateral and anteroposterior views 516 

673. Separation of the lower femoral epiphysis. Lateral and anteroposterior views 517 

674. Femur; separation of lower epiphysis 518 

675. Separation of the lower femoral epiphysis 519 

676. Method of reduction of separation of the lower epiphysis of the femur 520 

677-678. Tear-fracture of a part of the external condyle of the femur 521 

679. Tear-fracture of a part of the internal condyle of the femur 521 

680. Method of determining abnormal mobility in fracture of the external condyle 

of the femur by a forced varus position 522 

681. Method of determining abnormal mobility in fracture of the internal condyle 

of the femur by a forced valgus position 522 

682. Myosites ossificans traumarica following strain of adductor muscles 523 

683. Incomplete transverse fracture of the patella 526 

684. Transverse fracture of the patella, lower third 526 

685. Transverse fracture of the patella with marked rotation of the lower fragment 526 

686. Transverse fracture of the patella, middle third, with separation of the frag- 

ments 526 

687. Incomplete transverse fracture of the patella, lower third, direct violence 527 

688. Transverse fracture of the patella, middle third. Marked separation of frag- 

ments 527 

689. Transverse fracture of the patella, with moderate bony union 527 

690. Old transverse fracture of the patella, upper third, with extreme separation 

of the fragments 527 

691. Drawing to show the mechanism of fracture of the patella by muscular action 528 

692. Method of non-operative treatment of fracture of the patella on inclined plane 533 

693. Application of the posterior hand splint in fracture of the patella to be used 

during convalescence 533 

694. Fracture of the patella 534 

695. Fracture of the patella, untreated for six months 537 

696. Fracture of the patella showing moderate approximation by silver wire suture 537 
697-700. Examples of suture of patellar fragment? in which the silver wire used 

for suture was either extruded or broken 538 

701. Right tibia, anterior view 541 

702. Right fibula, anterior view 542 

703. Tear-fracture of tibial tubercle 544 

704. Normal epiphysis of upper end of tibia with separate centre of ossification for 

tibial tubercle 544 

705. Tear-fracture of tibial tubercle 544 

706. Comminuted fracture of the upper end of the tibia and fibula 544 

707-708. Fracture of the external tuberosity of the tibia 545 

709. Fracture of external tuberosity of the tibia 545 

710. Fracture of internal tuberosity of the tibia 545 



XX H ILLUSTRATIONS 



FIG. 



PAGE 



7 1 1 -7 1 2. Longitudinal T- or Y-fracturc of the upper end of the tibia, with separation 

of both tuberosities 546 

713-714. Fracture of the upper end of the tibia (T-shaped, articular of the head) 

and of the fibula 546 

715 717. Types of compression fracture of the upper end of the tibia including 

both tuberosities 547 

718 7 n). Transverse anteroposterior fracture of the upper end of the tibia, and 

oblique fracture of the neck of the fibula 54§ 

720-72 1 . Lateral oblique fracture of the tibia with fracture of the fibula 548 

: 22 723. Transverse fracture of the upper end of the tibia 549 

724. Fracture of the internal tuberosity of the tibia 549 

725. Fracture of the intercondylar eminence 549 

~2(\ Anteroposterior oblique fracture of the upper end of the diaphysis of the tibia. . 550 

727. Incomplete transverse fracture of the upper ends of the tibia and fibula 550 

728-730. Fractures of the upper end of the fibula 55 2 

731. Relation of the external peroneal nerve with the head and neck of the fibula 553 

732. Fracture of the head of the tibia; epiphyseal 5.54 

733. Spiral fractures of the shafts of the tibia and fibula 555 

734. Comminuted fracture of the shaft of the tibia and fracture of the shaft of the 

fibula 556 

735. Transverse fracture of the shafts of the tibia and fibula 556 

736. Oblique fracture of the shaft of the tibia with a double fracture of the shaft 

of the fibula 556 

737. Oblique fractures of the shafts of the tibia and fibula, considerable overriding 

of the fragments 556 

738. Spiral fracture of the shaft (low) of the tibia with spiral fracture of the shaft 

(high) of the fibula 557 

739-740. Double spiral fracture of the shaft of the tibia 557 

741 . Spiral fracture of the shaft of the tibia 557 

742. Double spiral fracture of the shaft of the tibia 558 

743. Old healed fracture of the shaft of the tibia and recent fracture of the shaft 

of the fibula 558 

744. Oblique fracture of the shafts of the tibia and fibula 558 

745-746- Incomplete fracture of the shaft of the tibia in a boy aged 12 years 558 

747-748. Oblique fracture of the shaft of the tibia; boy aged 5 years 559 

749. Tibia and fibula (left). Fracture of both bones below middle 560 

750. Tibia and fibula, right. Fracture of both l>ones; union 560 

751. Characteristic displacement of fragments in olbique fractures of the shafts of 

the tibia and fibula 560 

752. Method of determining abnormal mobility and crepitus in fract ure of the shafts 

of the tibia and fibula 561 

753. Method of measurement from the internal tuberosity to the internal malleolus 

of the tibia to determine shortening 561 

754. Showing how shortening may take place 563 

755. Method of treating fractures of both bones of the leg in a swinging fracture box . 564 
756a. Modified Zuppinger traction apparatus for treating fractures of both bones 

of the leg 565 

IS 6 *, 756c. Cabot posterior wire splint used in treating fractures of both bones 

of the leg unattended by deformity 565 

757-758. Transverse fractures of shafts of tibia and fibula 566 

759-760. Transverse fracture of the shafts of the tibia and fibula 566 

2. Oblique fractures of the shafts of the tibia and fibula 567 



ILLUSTRATIONS xxiii 

KG. PAGE 

763-764. Oblique fractures of the shafts of the tibia and fibula 567 

765-766. Photographs showing result obtained in fracture of shafts of tibia and 

fibula 5 68 

767-768. Transverse fracture of the tibia with incomplete fracture of the fibula 569 

769-770. Transverse fracture of the tibia and incomplete fracture of the fibula 569 

771. Photograph showing a result often obtained in badly comminuted open frac- 

tures of the bones of the leg followed by suppuration 570 

772. Spiral fracture of the shaft of the tibia 571 

773. Transverse fracture of the shaft of the tibia 571 

774. Transverse fracture of the shaft of the tibia with the separation of a three- 

cornered fragment 57! 

775. Comminuted fracture of the shaft of the tibia 571 

776. Comminuted fracture of the shaft of the fibula. Direct violence 572 

777. Oblique fracture of the shaft of the fibula 572 

778-782. Types of supramalleolar fractures of the tibia and fibula 573, 574 

783. Supramalleolar fracture of tibia and fibula 575 

784. Fracture of internal malleolar portion of lower epiphysis of the tibia 577 

785. Separation of the lower tibial epiphysis with fracture of the fibula 577 

786. Separation of lower tibial epiphysis with fracture of lower end of diaphysis and 

fracture of the lower end of the fibula 579 

787. Showing the normal structures of the ankle-joint 580 

788. Showing the most common types of fracture about the ankle-joint, and 

methods of reduction of these types of fractures 581 

789. Fracture of fibula with rupture of internal lateral and tibio-fibular ligaments . . . 582 

790. Fracture of the fibula with fracture of the internal malleolus 583 

791. Fracture of the fibula (low) with fracture of the internal malleolus 583 

792. Fracture of the fibula with fracture of the internal malleolus. Marked pos- 

terior displacement of the foot 584 

793. Method of determining crepitus in fracture of the lower end of the fibula by 

rocking of the lower fragment 585 

794. Method of determining lateral mobility of the ankle-joint in fractures of the 

malleoli 585 

795. Method of reduction of classic Pott's fracture by forced inversion of the foot 

and correction of posterior displacement if it is present 586 

796. Application of a pillow and side splints for temporary immobilization of frag- 

ments before placing the foot and leg in a gypsum case 586 

797. Method of holding the foot and leg while a gypsum case is being applied 587 

798. Fracture of the fibular malleolus with fracture of the internal malleolus and 

posterior articular edge of the tibia 588 

799. Fracture of the fibular malleolus, internal malleolus and posterior articular 

edge of the tibia 589 

800. Fracture of the fibula, of the internal malleolus and of the external articulat- 

ing edge of the tibia 589 

801-803. Types of fracture of the malleoli by inversion and adduction of the foot. 592 

804. Atypical inverted Pott's fracture 593 

805-806. Isolated fracture of the internal malleolus 594 

807-808. Isolated fracture of the external malleolus 595 

809-810. Fracture of the anterior articular edge of the lower end of the tibia 597 

811. Anterior view of bones of foot 599 

812. Rontgenogram showing bones of normal foot, lateral view 600 

813. Rontgenogram showing normal bones of foot, anteroposterior view 602 



jorfv ILLUSTRATIONS 

FIG. PAGE 

M4. Fracture of neck of astragalus 603 

815. Compassion fracture of neck of astragalus 604 

816. Fracture of neck of astragalus 604 

817. Fracture 1 if external process of astragalus 605 

nre of the both- of the astragalus with outward dislocation of anterior 

fragment 606 

B19. O impression fracture of body of astragalus 607 

820. Compression fracture of body of astragalus and of calcaneum with disloca- 

tion at astragalo-scaphoid joint 607 

821. O >mpression fracture of body of astragalus 608 

*2 2. Fracture of the posterior process of the astragalus 608 

5. Types of tear-fracture of the posterior process of the calcaneum 609 

826-828. Types of fracture of posterior process of calcaneum 610, 61 1 

829-S31 . Types of compression fractures of the calcaneum 612 

832. Fracture of epiphysis of posterior process of calcaneum 613 

833. Method of determining lateral normal motion in the foot 614 

834. Fracture of left calcaneum, anterior and posterior views 614 

835. Cotton's method of reduction of a fracture of the posterior process of the cal- 

caneum with upward displacement of the fragment 615 

836. Cotton's method of correcting lateral broadening below the malleoli by com- 

pression of fragments with a hammer and piece of felt 616 

837. Fracture of the body of the calcaneum with upward displacement of the 

fragment .' 617 

838. Drawing to show the pull exerted by the tendo-Achilles in fracture of the pos- 

terior portion of the body of the calcaneum 617 

839. Method of approximation of fragments in fracture of posterior portion of ■ 

body of calcaneum by open operation 618 

!. Types of fractures of the tuberosity of the tarsal scaphoid 619 

S43. Fracture of cuboid 620 

is Tear-fractures of the internal cuneiform 620 

;nrninutcd fracture of the first metatarsal 623 

•nminuted fracture of the first metatarsal, longitudinal in type 623 

848. Transverse fracture- of the first and second metatarsals 623 

. ngitudinal fracture of the first metatarsal 623 

B50. Fracture dislocation of the base of the first and of the shafts of the second, 

third and fourth metatarsals 624 

851. Ti hire of the shaft of the second metatarsal 624 

racture of the shaft of the second, third and fourth metatarsals 624 

- 5. Types of fracture of the tip of the tuberosity of the fifth metatarsal 625 

57. Typi - of frac'urc of the base of the tuberosity of the fifth metatarsal. . . 626 
;■). Types of fracture through the proximal end of the shaft of the fifth meta- 

626 

64. Type of fracture of the -haft of the fifth metatarsal 627 

865. Method of dctcrming abnormal molality and crepitus in fracture of the shafts 

of the metatarsals (, 2 $ 

866. Ti imal phalanx of the great toe 629 

blique fracture of the proximal phalanx of the second toe 629 

' 'he proximal phalanx of the fifth toe £, 

minuted fracture of the distal phalanx of the great toe, involving the epi- 

6, 

B70. Pi phalanx of greal tot 6 3 o 



ILLUSTRATIONS xxv 

FIG. PAGE 

871 . Constant sesamoid bones of the thumb 631 

872. Shows only one constant sesamoid bone at the metacarpophalangeal joint of the 

thumb, one accessory sesamoid head of second metacacarpal, one at head of 

third metacarpal, and two at head of the fifth metacarpal 631 

873-874. Shows two accessory carpal sesamoid bones in tendon sheaths of flexor 

tendon to fifth finger 632 

875. Constant sesamoid bones at head of the first metatarsal bone 632 

876-877. Types of os trigonum 632, 633 

878. Os tibiale externum, in the tendon sheath of the tibialis posticus tendon 633 

879. Double os peroneale, situated in the tendon of the peroncus longus muscle. . . 633 

880. Accessory sesamoid in the tendon of the gastrocnemius muscle 634 

881. Shows the two constant sesamoids at the head of the first metatarsal, and 

accessory sesamoids at the heads of the second, third, fourth and fifth meta- 
tarsals 634 

882. Comminuted fracture of the 'tibial sesamoid of the great toe 635 

883. Fracture of the tibial sesamoid of the great toe 635 

884. Fracture of fibular sesamoid, accompanying comminuted fracture of the head 

of the first metatarsal 636 

885. Fracture of the tibial sesamoid 636 

886. Fracture of the fibular sesamoid, run over by a motorcycle 636 

887. Fracture of the tibial sesamoid; injured while playing base-ball 636 

888. Old fracture of sesamoid in a base-ball player 637 

889. Fracture of the sesamoid of the thumb 637 

890. Fractures of right humerus and both clavicles 640 

891. Fracture of shaft of femur, at end of ten weeks 641 

892-893. Radiographs of normal and injured femur for comparison, (10 days and 

four months) 642 

894. Long side splint used in fracture of shaft of femur 643 

895. Aluminum splint used in fracture of humerus 644 

896. Makin's five types of fracture observed in military life 647 

897-8970. Gunshot fractures of the palate and the body of the sphenoid bones 648, 649 
8976. Perforating gunshot fracture of the frontal and the nasal bones 650 

898. Gunshot fracture of the mandible 651 

899. Gunshot fracture of the left humerus 652 

900. Gunshot fracture of the humerus; note butterfly type of fracture, and frag- 

mentation of the bullet 653 

901-902. Gunshot fractures of the carpus 654, 655 

903. Gunshot fracture of the proximal phalanx of the middle finger 655 

904. Gunshot fracture of the tibia 656 

905. "Aeroplane" bracket splint for holding arm in abduction and forearm in ex- 

tension 657 

906. "Aeroplane" bracket splint to hold arm in abduction and forearm flexed. . . . 658 

907. Gypsum encasement with basket braces of wire and gypsum gauze for im- 

mobilization of infected open and comminuted fractures 659 

908. Tibia and fibula, upper extremities of right 660 

909. Basket plastic splint with steel bones arranged for immobilization with extented 

knee and some traction on fracture 661 



TREATISE ON FRACTURES 



CHAPTER I 

GENERAL CONSIDERATIONS 

Definitions. — A fracture is a sudden separation of osseous fibres due 
to injury ; in a general way it refers to the breaking of a bone or carti- 
lage. It is applied somewhat incorrectly to a traumatic separation of an 
epiphysis from its diaphysis, though that lesion is properly called a 
diastasis. 

A dislocation or luxation is the sudden displacement of the articular 
surfaces of the adjoining bones from their normal relation. The term 
is also used to describe the displacement of an articular or intra- 
articular fibrocartilage from its normal relations. A dislocation is 
complete when the normal articular surfaces of the bone involved are 
entirely displaced ; incomplete when the articular surfaces of the bone 
involved still retain partial contact. The latter condition is more 
properly termed a subluxation. 

A sprain or distortion may be described as an injury to a joint or 
the structures in proximity to a joint, in which the joint motions have 
been forcibly carried beyond normal physiological limits. Sprains are 
usually the result of indirect violence, although they may be produced 
by muscular action alone. The force would probably result in a fracture 
or dislocation if the violence were greater. The injury generally con- 
sists in partial or minute tearing of portions of ligaments, tendons, or 
fascias, or the bruising of the articular cartilages. 

A sprain-fracture is the partial or complete separation of a small 
portion of a bone near a joint to which a tendon or ligament is attached, 
as a result of sudden violence acting upon the tendon or ligament 
involved. 

Statistics. — A review of statistics showing the liability of individual 
bones to fracture shows that, as a rule, these statistics are incomplete as 
to classification or that the location of fractures of individual bones is 
not given. Another source of error is the fact that many fractures are 
omitted entirely, many are diagnosed as subluxations, and many as 
sprains. This results in the inevitable worthlessness of the average 
statistics. 

The following statistics are deemed valuable : The combined sta- 
tistics of Bruns, Chudowsky, Immelmann and those of Plagemann, but 
one can realize the inaccuracies that are shown by combined statis- 
tics. The records of Plagemann from the Rostock clinic are prob- 

1 



2 TREATISE ON FRACTURES 

ably the mosl accurate that arc anywhere presented. They are divided 
into three groups: The statistics of the first and second groups are 
based in many cases on X-ray examinations; those of the third group 
are based on X-ray examinations of all suspected fractures. 



TABLE I. 





A 
Brans 


Chudowsky 


c 

Immc-lmann 


D 

Plagemann, Rostock Clinic 






3664 Fractures. Years 1891-1910 




Rostock Statistics 




Oct. 1, 1891 to 
Oct. 1, 1899 


Oct. 1, 1899 to Oct. 1, 1905 to 
Oct. 1, 1905 Aug. 1, 1910 


Fractures 


8560 2366 


4048 


1106 


1165 


1393 


Skull (vault 

and base) 

Nasal 

Superior maxilla. 
Inferior maxilla.. 


/', r Per 
cent. cent. 

292= 3.4 90= 3-8 
95= 1.1 23= 0.97 
55= 0.6 12= 0.5 

102= 1.1 44= 1.9 


Per 

cent. 

20 = )i 


Per 
cent. 

31= 2.8 

9= 0.81 
10 = 0.9 


Per 
34 = 3-07 

7= 0.63 
7= 0.63 
5= 0.452 


Per 
cent. 

59 = 4-23 
9 = 0.64 
6 = 0.43 

11=0.79 


Total 


544= 6.3 169= 7.14 




61= 5-52 


53= 4-55 


85 = 6.11 






Vertebrae 

Pelvis 

Ribs 


39= 0.4 14= 0.59 
70 = 0.8 23 = 0.97 
*I f ;= 9.5 193= 8.15 


35= iM 
70= l% 


23= 2.03 
8= 0.72 

67 = 6.05 
2= 0.18 
9= 0.81 


24= 2.17 
6= 0.54 

29 = 2.62 
1 = 0.09 
5= 0.452 


23= 1-65 
17 = 1.22 
40 = 2.87 
5 = 0.359 








loo = 1.1 


20 = 0.84 


63= l% 




l 3 0.93 


Total 




256= 10., So 




109= 9.85 


65 = 5-57 


89 = 7-03 






Clavicle 

HumiTiis 

Ulna and radius.. 
Ulna 


C60 = I 1.2 

752= 8.7 

2 15= 2.5 
103= 1.2 


1 13= 417 
210= 8.17 
125= 5-32 

) 79 = 3-3-t 

253= 10.69 
} 55= 2.29 

955 39-65 

251 = 10.60 1 
25= i-«5 

352 = 14-87 
59 M6 
74= 3-12 

112= 4.69 


40= 1 
940 = 23K 

1300 = 32;^ 

35 = % 
55 = ft 

15" = 3% 


69= 6.23 

I28=ii. 4 § 
84= 7-5 

; 23= 2.03 
123= II. 1 


60= 5.4 
131 = 11.85 
147=133 

27= 2.44 

61= 5-5 
3= 0.27 
33= 3 
98= 8.86 


54= 3-87 
194=13-92 
134= 9-62 


' flecranon 

Radius 


Ulna 

20=1.43 

Olecranon 
and 

coronoid 
process 
11 = 0.79 


s 


Carpus 


73-5-24 
29 = 2.08 
35 = 2.51 
75 = 5-405 


rpals 


M9 4-8 
1086- 12.6 

1-3= 1.4 
160 [.{ 


'4= 1-3 




2480 61.26 


444 = 40.14 


500= 42.91 


571 =40.99 




425= in'-; 
120= 3 

MO= 3'2 

'45= 3 5 o 
3" = 3 * 


173=15-5 
12= 1.08 

166 = 15 
14= 1-3 
33= 3 

11 = 1 
3= 0.27 


151 = '3-6 
12 = 1.1 

213 = 19.2 
42= 3-8 
27= 2.44 
17= 1.5 
12= 1.08 
12= 1.08 




1 fibula. 
Tibia 
Fibula 


150= 10.81 
35= 2.51 

168 = 12.06 
61= 4.38 




57= 4-09 


Phalanf 


45= 0.5 


37= 2.65 
49= 3-51 
24= 1.71 


Totals 






423 = 38.24 


487 = 41.8 


585 = 41-99 



GENERAL CONSIDERATIONS 3 

TABLE II (Plagemann) 

A. Fractures of the skull (50 cases, 4.23 per cent.). 

B. Fractures of the extremities: 

1. Fractures of the humerus (194 cases, 13.39 P er cent.): 

(a) Of the upper end (73 cases, 5.24 per cent.): 

(1) Fractures of the anatomical neck 4 (0.29) 

(2) Fractures of the greater tubercle 30 (2.15) 

(3) Fractures through the tubercle 10 (0.71) 

(4) Separation of the upper epiphysis 7 (0.509) 

(5) Fractures of the surgical neck 22 (1.57) 

(b) Of the shaft 18 (1.29) 

(c) Of the lower end: 

(1) Supracondylar fractures 43 (3.08) 

(2) Supracondylar — intercondylar 11 (0.78) 

(3) Fractures of the external condyle 15 (1.07) 

(4) Fractures of the internal epicondyle 18 (1.29) 

(5) Separation of the lower epiphysis 10 (0.71) 

(6) Fracture of the cubital process 6 (0.43) 

2. Fractures of the bones of the forearm (238 cases, 17.09 per cent.): 

(a) Both bones of the forearm (134 cases, 9.62 per cent.). 

(1) Fracture of the upper ends of both bones 7 (0.509) 

(2) Fracture of the shafts of both bones 47 (3.37) 

(3) Fracture of the lower ends of both bones 80 (5.74) 

Darunter Fr. Supra-epiphysaria antibrachii 13 (0.93) 

(6) Fractures of the radius alone (73 cases, 5.24 per cent.): 

(1) Fractures of the head and neck of the radius 23 (1.65) 

(2) Fractures of the shaft of the radius 12 (0.85) 

(3) Fractures of the lower end of the radius 38 (2.72) 

(c) Fractures of the ulna alone (31 cases, 2.22 per cent.): 

(1) Fractures of the olecranon and coronoid processes n (0.78) 

(2) Fractures of the shaft of the ulna 15 (1.07) 

(3) Fractures of the lower end of the ulna 5 (0.359) 

3. Fractures of the bones of thediand (139 cases, 9.98 per cent.) : 

(a) Carpal fractures (29 cases, 2.08 per cent.): 

(1) Fractures of the scaphoid 13 (0.03) 

(2) Fractures of the semilunar 5 fo.359) 

(3) Fractures of the cuneiform 3 (0.21 ) 

(4) Fractures of the os magnum 1 (0.07) 

(5) Fractures of several carpal bones 7 (0.509) 

(b) Metacarpal fractures (35 cases, 2.51 per cent.): 

(c) Fractures of the phalanges (75 cases, 5.405 per cent.). 

4. Fractures of the femur (150 cases, 10.81 per cent.): 

(a) Fractures cf the upper end (84 cases, 6.04 per cent.) : 

(1) Fractures of the neck of the femur( 60 cases, 4.307 per cent.) : 

(a) Fractures of the neck, close to head it (0.78) 

(b) Fractures of the neck, intermediate 20 (1.43) 

(c) Fractures through base of neck and trochanters. ... 5 (0.359) 

(d) Fractures of the neck at base 24 (1.79) 

(2) vSeparation of the upper epiphysis 4 (0.29) 

(3) Fractures through the trochanters 7 (0.509) 

(4) Fracture of the great trochanter 2 (0.143) 

(5) Fractures below the trochanters 11 (0.78) 

(b) Fractures of the shaft of the femur (55 cases, 3.94 per cent). 

(c) Fractures of the lower end of the femur (12 cases, 0.89 per cent.): 

(1) Supracondylar fractures 8 (0.57) 

(2) Fractures of the internal epicondyle 7 (0.509 J 

(3) Separation of the lower epiphysis of the femur 2 (0.143) 

(4) Fractures of the condyles 2 (0.143) 

5. Fractures of the patella (35 cases, 2.51 per cent.): 

(a) Fractures of the upper third 5 

(b) Fractures of the middle third 22 

(c) Fractures of the lower third 8 

6. Fractures of the bones of the leg (286 cases, 20.53 P er cent.): 

(a) Fractures of tibia and fibula (168 cases, 12.06 per cent.). 

(1) Fractures of the upper end of tibia and fibula 4 (0.29) 

(2) Fractures of the shafts of tibia and fibula 92 (6.604) 

(3) Supramalleolar fractures (Malgaigne) 22 (1.57) 

(4) Fractures of the lower ends of tibia and fibula 50 (3.59) 



TREATISE ON FRACTURES 



TABLE II (Plagemann)— Continued 

. turcs of the tibia, alone (6i cases, 4.3S per cent.): 

ictures of the upper end of the tibia 19 (r.36) 

.cttires of the shaft of the tibia 24 (1.79) 

ictures of 'he lower end of the tibia 18 (1.29) 

Fractures of the fibula, alone (57 cases, 4.09 per cent.): 

1 1 ) Fractures of the head and neck of the fibula 13 (0.9.?) 

< j! Fractures of the shaft of the fibula 30 (2.15) 

, tares of the external malleolus I-l (1.005/ 

mes of the foot ("114 cases, 8.18 per cent.): 
Fractures of the tarsal bones (37 cases, 2.65 per cent.): 

t 1 1 Fracture of the calcaneus, alone 17 (1.22) 

icture of the astragalus, alone 5 (o.35Q) 

alcaneus and astragalus 4 (0.29) 

ICture of the scaphoid 7 (0.509) 

icture of the cuboid 1 (0.07) 

(6) Fracture of the cuneiform 3 (0.21) 

•t the metatarsals (49 cases, 3.51 per cent.). 
ractures of the phalanges (24 cases, 1.71 per cent.). 
((/) Fractures of the sesamoids (4 cases, 0.29 per cent.). 
of 'he clavicle (54 cases, 3.87 per cent.). 
q. Fractures of the scapula (13 cases, 0.93 per cent.). 

TABLE III (Plagemann) 

51 \TISTIC- FROM ROSTOCK CLINIC BASED UPON 1 393 CASES. CONFIRMED BY RONTGENOGRAM 



H B 



- 


= 


i 




n 


— 


! 


6 


7 


8 


5 


3 


4 


10 


2 




2 


4 


2 


8 



Number of 
Cases and 
Percentages 



Fracture of skull 3 

Fracture of the vertebra' 

Fracture of the pelvis 2 

Fracture of the ribs 1 

Fracture of the sternum 

Fracture of the scapula 

of the clavicle 27 

Upper exi remit y ( 57 1 cases, 40.99 per cent.) 
Humerus, fractures of (194 cases, 13.93 
per cent.}: 

Fracture of anatomical neck 

Fracture of greater tuberosity 

Fracture through the* tuberosities 

'ire of the surgical neck I 

Epiphyseal separation, upper end I 

Fracture of the shaft 5 

ire. supracondylar 36 

ire. supracondylar-intercondylar . . 

ture, external condyle 5 

Fracture, internal epicondyle 

Epiphyseal separation, lower end N 

Fracture, cubital process 

Radius and ulna, fractures of (238 cases, 
17. <x> per cent.): 
ture both bones, upper end 1 



.: 



-.-<■ of shaft of both bones. 

in both bones, lower end 

Radius. 6 73 cases. 5.24 per 

I and neck of radius 



ins. lower end 

1 i percent.) 

■! and coronoid 



• 1. shaft 

r end 



23 



I 


1 


2 


II 


4 


6 


2.5 


5 


'5 


5 


9 


3 


4 


4 


2 


-3 


5 


15 


2 


4 


4 


2 


4 


6 


2 




2 



59=4-23 
23 = 165 

17 = 1.22 

40 = 2 87 

5=0-359 
13=0.93 

54=3-87 



4 = 0.29 
30 = 2.15 
10 = 0.71 
22 = 1.57 

7=0.509 
18 = 1.29 
43=3-o8 
11=0.78 
15 = 1.07 
18 = 1.29 
10 = 0.71 

6 = 0.43 



7=0509 

47=3-37 
1 80 = 5.74 



• ■- 2;, = !. 65 
. .. 12=0.85 
4 I 80 = 5.74 



11=0.78 
15 = 1 .07 
5=0.359 



GENERAL CONSIDERATIONS 



TABLE III (Plagemann) — Continued 

STATISTICS FROM ROSTOCK CLINIC BASED UPON I393 CASES. 
RONTGENOGRAM 



CONFIRMED BY 





2 


° 


3 | h 


5. 


i 


«S 


g, Number of 
H Cases and 
1- ! Percentages 


Bones of hand, fractures of (139 cases- 
9.98 per cent.) : 
(a) Carpal fractures (29 cases, 2.08 per 
cent.) : 

Fracture of the scaphoid 

Fracture of the semilunar 


1 
8 


1 

1 

5 
12 


4 

1 

8 
22 


3 

1 

4 
7 
18 

2 

2 

1 

1 
1 

4 


3 

2 
13 

3 
3 

1 

, 5 

1 
19 

7 
10 

6 
2 
2 

6 
5 

2 

1 


1 


1 


• 13=0.93 
• 5=0-359 










Fracture of several carpal bones 


8 

3 

5 

6 

1 

1 

7 


2 . 
2 . 

2 

5 
2 

2 1 

2 

1 
3 


• 7=0.509 

• 35 = 5405 

■ 75 = 5405 

3 11=0.78 

8 20 = 1.43 

1 5=0-359 

2 24 = 1.79 
. 4 = 0.29 

■ 7=0.509 

1 2=0.149 

2 11=0.78 
1 55=3-94 

• 8=0.57 




Lower extremity (585 cases, 41.99 per cent.) 

Femur, fractures of (150 cases, 10.81 per 

cent.) : 

Fracture of neck of femur below head . 

Fracture of neck of femur about 


Fracture through trochanters and neck 
Fracture of neck of femur near tro- 








Separation of upper epiphyses of femur 

Fracture through the trochanters 

Fracture of the great trochanter 

Fracture below the trochanters 

Fracture of the shaft of the femur .... 

Fracture supracondylar, of femur 

Fracture of internal epicondyle 


3 
30 
3 

1 
7 


4 

1 

2 
2 

2 
3 

10 
9 

2 

10 
3 

5 
1 


5 


Fracture of condyle of femur 

Separation of lower epiphyses of femur 
Patella, fractures of (35 cases, 2.51 per 


..1 
"1" 


7 

11 

5 

7 

2 

3 
2 

1 

1 


2 

1 
<5 

2 

1 
4 


. 1 2=0.143 

■ 2=0.143 

1 35=2.51 

. 4 = 0.29 
4 92=6.604 

2 22 = 1.57 
2 : 50 = 3-59 

1 19 = 1.36 

■ 24=1.79 
. 18 = 1.29 

1 , 13=0.93 
1 30 = 2.15 
. 14 = 1.005 


Bones of leg, fractures of (286 cases, 20.53 

per cent.): 

Fracture of upper end of tibia and fibula 

Fracture of shaft of tibia and fibula. . . . 

Intramalleolar fracture of both bones . . 

Fracture of lower end of tibia and fibula 

Tibia, fractures of (61 cases, 4.38 per 

cent.): 


13 

4 

4 
3 
5 

7 
6 

1 


1 

23 

6 

5 
1 
4 

11 
3 

6 

1 

2 




Fracture of lower end of tibia 

Fibula, fractures of (57 cases, 4.09 per 
cent.): 
Fracture of upper end (head and neck) 


Bones of foot, fractures of (1 14 cases, 8.18 
per cent.): 






• 5=0-359 
. 4 = 0.29 
. 7=0.509 


Fracture of calcaneus and astragalus. . 




Fracture of cuboid 










1 


2 

12 
6 
2 












1, 




6 
5 

1 


4. 


5 


• 49=3-51 




4 8 























TREATISE OX FRACTURES 

Relationship of Fractures to Age, Sex and Season.— The influence 
up. mi the production of fractures is shown by Plagemann, not 
only as regards the periods of life in which fractures are most fre- 
quently seen, but also in the fact that certain types of fractures are 
more frequent at van', .us periods of life. In the first and second decades 
the in. ist frequent f< >rms of fracture are the incomplete, the subperiosteal 
and epiphyseal separations, the bones most frequently involved being the 
clavicle, the lower end of the humerus, and the lower end of the radius. 
During the third, fourth, and fifth decades, the fractures most fre- 
quently met are those of an occupational violence and those of direct 
violence, the bones most frequently affected being the tones of the leg. 
the femur, the humerus, and the skull. During the sixth and seventh 
decades other influences are at work in the production of fractures. In 
this period we find the bones more brittle, the muscular tone of the 
body diminished, the special senses not so acute, and as a result we have 
most frequently fractures of the upper end of the femur, of the upper 
end of the humerus, and the lower end of the radius. It may be stated 
that, as a general rule, fractures occur in the greatest number during 
the second, third, and fourth decades of life. 

Fractures are more frequently seen in men than in women. They 
occur in the proportion of about 4 to 1. The fact of this dispropor- 
tion is due to the more active life of the male at all ages, to the occupa- 
tion^ assumed by the male, and to the fact that men spend so much 
more time out of doors. During the third, fourth, and fifth decades 
fractures occur among men six or seven times more frequently than in 
women. In infancy and old age the proportion of fractures occurring 
in the two sexes is about equal. In old age fractures are a little more 
frequent in the female and are most often fractures of the upper end 
of the femur. 

The influence of season in the occurrence of fractures is shown in 
the frequency of fractures seen in the summer season as compared with 
the winter season. This is due entirely to the fact that we are more 
active, spend more time out of doors, and that the various building 
trade- and all business, in fact, are carried on more actively in the 
summer -ens. , n . The occurrence of ice and snow in winter may perhaps 
modify these conclusions in sonic places. 

Etiology of Fractures.— For the production of a fracture certain 
etiological factors must he present. These may l>e divided into (T 1 
predisposing causes, and 1 _' 1 the exciting or determining causes. 
Fractures may be divided into (1) traumatic and (2) pathologic 
fractures. 

Predisposing Causes.— Certain bones are predisposed to fracture 
on account of their exposed position, curves, their function as levers, or 
the small proportion of osseous tissue. Other bones are less liable to 



GENERAL CONSIDERATIONS 7 

fracture owing to their unexposed position, their mobility, and the pro- 
tection afforded by overlying muscles. Other factors are the elastic 
and yielding character of bones in infancy and adolescence, and in old 
age the brittle character of the bones, from senile atrophy and thinning 
of the cortex of the bones. 

A predisposing factor of diastasis or epiphyseal rupture in early 
age is the presence of the epiphyseal cartilages ; epiphyseal separations 
occur only at this period of life. 

Exciting Causes of Fracture. — The exciting causes of fracture 
are (i) external violence, and (2) muscular action. 

Fractures by External Violence. — These may be divided not only 
by the mechanical modes of their production, but also by the clinical 
difference into two classes — fractures by direct violence and fractures 
by indirect violence. In fractures by direct violence the bone is broken 
immediately beneath the point of the fracturing force. In fractures by 
indirect violence the fracture does not occur at the point immediately 
below the point of the producing force, but at a point distant. Fractures 
by direct violence may be complicated by extensive injury to the over- 
lying soft parts, by sloughing of the parts, or by the production of an 
open or compound fracture. Examples of fracture by direct violence 
are fractures of the calcaneum by falls upon the feet, fractures caused 
by kicks, by falling timbers and by being struck with some heavy instru- 
ment, and gunshot fractures. In fractures by indirect violence the 
fracturing force is conveyed through the intervening bones; and the 
break occurs by leverage, torsion, or traction. Such forces produce 
occasionally transverse fractures, more generally, oblique, spiral, or 
comminuted fractures. Examples of fractures by indirect violence are 
fractures of the clavicle from a fall upon the hand, oblique or spiral 
fractures of the bones of the leg, fractures by torsion seen in fractures 
of the humerus and the so-called strength test, fractures by traction 
seen in fractures at lower end of elbow and at ankle in forced flexion, 
extension, adduction, or abduction. 

Fractures by indirect violence more frequently involve the long 
bones because of their length, shape, and muscular and ligamentous 
attachments. Fractures by indirect violence may be modified according 
to the condition of the muscles of the part, the direction of the fractur- 
ing force, the position of the parts, and the anatomical structure of the 
bone involved. This is illustrated by the various forms of fracture that 
may occur in a fall upon the palm of the hand. Thus we may have 
fractures of the radius, humerus, or clavicle. 

Fractures by Muscular Action. — Bones may be fractured (1) by 
the sudden contraction of muscle alone; (2) by contraction of muscles 
with part of the bone fixed so that a lever action is produced ; and ( 3 ) by 
the sudden muscular action of a part in motion producing sudden arrest 



8 TREATISE ON FRACTURES 

of the part Examples of the first class are fractures of the patella, of 
the olecranon, of the tuberosity of the calcaneum; examples of the 
second class are spiral or oblique fractures of the humerus in wringing 
out clothes, and in the so-called strength test; examples of the third 
class arc fractures pr< uluced by throwing and lifting, shovelling. Other 
c xamples of fractures produced by muscular action are fractures of the 
ribs from violent coughing, fractures of the bones of the leg in missing 
Meps, fractures of the long bones during the contractions of tetanus. 

The patella is the bone most frequently fractured by muscular 
action. Xext in order are the olecranon, the greater tuberosity of the 
humerus, occasionally the coracoid and acromion processes of the 
scapula, and many atypical fractures at the site of insertion of powerful 
muscles. Sprain fractures form a large class of fractures produced by 
muscular action. 

Gunshot Fractures. — In considering the etiology of gunshot frac- 
tures, one must bear in mind that the resulting lesions vary greatly, 
depending upon the velocity of the bullet, its size, the part of the bone 
involved, and upon whether the lesions are produced in military or civil 
li fe. The character of the fracture produced by the high velocity bullet 
of war is entirely different from that produced in the ordinary revolver 
wound. Various degrees of bone lesion may occur. These may be 
classified as (i) a fissured fracture of one side of the cortex. (2) A 
depression of the cortex. (3) A transverse comminuted or fissured 
fracture without perforation of the bone. (4) A perforation of the 
bi 'tie. When this last form occurs in the spongy bone near the articular 
end of long bones or in flat bones, there is generally no comminution; 
when the shaft of the bone is involved there is generally extensive 
Assuring, comminution and destruction dependent upon the line of the 
projectile. (5) Cluttered or notched fractures may be produced when 
only a small portion of the circumference of the bone is involved. 

Fractures produced in military life are generally less extensive and 
less complicated by injury to soft parts than in former years, and the 
mortality has been greatly reduced. This is due to the high velocity of 
the bullet, its decreased size, its tendency to perforate without extensive 
comminution, and to the fact that wounds produced by it are, as a rule, 
.-'septic. Fractures produced in civil life by the ordinary low velocity 
large-sized bullet arc generally more comminuted, the destruction of the 
bone is greater, injury to the overlying soft parts is more extensive, and 
infection is more frequent. Fractures produced by bird-shot are rare, 
and arc only possible when the distance is short, or the bone injured is 
very thin. The associated lesion of the soft parts is the chief char- 
acteristic, and in some the associated injuries to viscera are very 
important. Shrapnel causes greal mutilation of all structures. 

Pathologic Fractures.— This term is given to that class of 



GENERAL CONSIDERATIONS 



9 



fractures which follows some slight injury, or muscular action alone, 
or without any demonstrable cause. Pathologic fractures are met in 
bones in which there is a brittleness or lack of resistance due to a local 
lesion or to a general disease producing a general fragility of the osseous 
structures. These fractures are sometimes termed spontaneous fract- 
ures. It can be readily understood why fracture may occur in bones the 
seat of local lesions in which the osseous tissue is destroyed and replaced 
by other forms of tissue. It has been observed by several authors that 
in cases in which spontaneous fractures occur there have been found in 




Pathologic fracture. Patient fell while wearing a brace, 
of right humerus. Pathologic fracture. 

the urine varying quantities of phosphoric acid. It has been suggested 
that this has been the result of the decalcification of the bone by some 
metabolic process, for which we are at present unable to account. These 
changes have been observed in cases of cancer and diabetes. 

Pathologic fractures may be classified as follows : ( i ) fractures 
the result of local bone disease; and (2) fractures in which the rare- 
faction of the bone is the result of a general disease. Of the first class 
fractures have been observed in the following conditions : 

A. Inflammatory processes : ( I ) Infectious osteomyelitis (Fig. 1 ) ; 
(2) tuberculous osteomyelitis. 



10 



TREATISE ON FRACTURES 



B. New growths of bone: (i) Sarcoma, primary (Fig. 2), and 
metastatic: (2) carcinoma, metastatic (Figs. 3 and 4); (3) benign 
bone cysts; 14) myeloma (albumosa) ; (5) lymphomata, malignant, 
metastatic: (6) metastatic tumors, thyroid in origin; (7) metastatic 
tumors from the adrenal: (8) echinococcus cysts. 

C. Aneurisms. 

/ ». Fracture the result of fragility of bones due to a general disease. 




Fig. 3. — Pathologic fracture of right femur, due to metastasis from carcinoma of left breast. Operated 

two years previously; local recurrence in scar, left axillary and supraclavicular regions. 

FlC. 4. — Pathologic fracture of right humerus due to metastatic growth from primary carcinoma of 

prostate gland. 

Of the second class fractures have been observed as follows: 
. /. Disease of the nervous system: (1) locomotor ataxia; (2) 
syringomyelia: (3) paresis. 

B. Rickets. 

C. Syphilid 

D. Idiopathic rarefaction. 

E. Rarefaction from disease. 

/'. Osteomalacia; scurvy; rarefaction due to chronic diseases: 
diabetes; osteitis deformans; osteogenesis imperfecta. 

Fractures in Utero. — lutra-uterine fractures are of two kinds, 
(\ 1 spontaneous fractures, and (2) pathologic fractures. The spon- 
taneous fractures may be the result of external violence, as blows, 
kicks, punctured and bullet wounds to the mother, which is extremely 
rare, but children have been borne with one or more fractures, some 
in a state of partial union in which there has been a history of external 



GENERAL CONSIDERATIONS 11 

violence. Pathologic intra- uterine fractures are generally the result of 
syphilis, rickets, osteochondrosis, parenchymatous osteitis or amniotic 
adhesions. Very often it is difficult to differentiate intra-uterine from 
intrapartum fractures. 

Intrapartum Fractures. — Fractures may occur during delivery. 
They may be spontaneous, but as a general rule they are the result of 
faulty management of the delivery, or disproportion of the size of 
the foetus and the pelvis, or undue haste. The bones most frequently 
fractured are the femur, humerus, clavicle, tibia and fibula, radius and 
ulna. The most common lesion is epiphyseal separation, although 
fractures of the shaft of the bone may occur. 

Varieties of Fracture. — Fractures should be classified as to variety 
as follows : 

A. Fractures considered in relation to the condition of the sur- 
rounding soft parts: Fractures are divided into two classes : ( I ) closed 
fractures; and (2) open fractures. A closed fracture is one in which 
there is no communication between the outside air and the seat of 
fracture. They are sometimes designated as simple or subcutaneous 
fractures. An open fracture is one in which the seat of fracture is 
exposed to atmospheric contact through a wound of the muscles, fascia, 
and skin. These fractures are sometimes called compound fractures. 
The open character of the fracture may be due to the direct vulnerating 
force, to projection of the end of a fragment through the soft parts, to 
the weight of the unsupported limb, or the subsequent sloughing of the 
overlying soft parts. It can be readily understood that open fractures 
are more dangerous and lead to more complications than closed fract- 
ures. Union is less rapid, and infection followed by osteomyelitis and 
septicaemia may occur, necessitating amputation occasionally as a last 
resort. Death is not unusual in infected fractures, unless the lesion is 
treated with an aseptic or antiseptic technic and great surgical skill. 

B. Fractures classified according to degree: Fractures may be 
classified as (1) incomplete, and (2) complete. 

1. Of the incomplete fractures (Fig. 5) we have: 

(a) Fissures. This form of fracture consists in a linear break 
without separation of the fragments to any appreciable extent. The 
most frequent sites are the vault and base of the skull ; and the humerus 
and tibia. When they involve the long bones they as a rule begin at the 
articular surface. 

(b) Infraction; green-stick or true incomplete fracture. This is 
a fracture involving only a portion of the diameter of the shaft with 
bending or angulation of the remaining fibres at the point of fracture. 
It occurs only in children, whose bones are normally elastic from a 
relatively large amount of organic material in their composition. It 



12 



TREATISE ON FRACTURES 



happens most frequently in the bones of the forearm, clavicle, tibia, 
femur and humerus. 

(c) Depressions or indentations. This variety of fracture is a 
depression of the cortex of the hone without complete fracture as a 
result of direct external violence. It is most commonly observed in 
the skull, involving the outer table, and in the spongy bones. 

i (/) Splitting of a portion of the cortex. This is a separation of 
the fibres of the cortex, with possibly a part of the underlying spongy 
bone as a result of direct violence. It does not involve the entire thick- 
f the hone and is generally produced by a sharp-cutting instru- 
ment like an axe or sabre. 




PlC. s.— Types of fractures, a. fissure; b. infraction; c, depression or indentation; d, splitting of 
portion of cortex; c, separation of an hypophysis; /, sprain fracture. 

i <• i Separation of an hypophysis; sprain-fracture. These frac- 
ture-. ..mir as a result of violent and sudden muscular action, tearing off 
a small process of attached bone, or are due to a sudden increase of 
tension^pon a ligament, producing the same result. Sprain- fracture 
■ frequent according to Ross and Stewart, who estimated it to 
occur in i ; per cent, of all fractures. The lesion generally consists of 
the tearing off of a small scale of hone, to which a muscle, tendon, or 
ligamenl is attached, close to a joint. 

\ complete fracture is one in which the line of fracture involves 
the entire thickness of the hone, separating it into two or more frag- 
ments. & 

(\ Fractures considered in relation to the direction and character 
of the line of fracture I Fig. f, ) ; 



GENERAL CONSIDERATIONS 



13 



(a) Longitudinal. Longitudinal fractures are those in which the 
line of fracture is not further from the long axis of the bone than 15 
or 20 degrees. They are extremely rare, except in perforating fract- 
ures such as are caused by gunshot wounds. 

(b) Transverse. In this variety the plane of fracture makes nearly 
a right angle with the long axis of the bone. Transverse fractures 
are rare. They are most frequently found in the lower end of the 
radius, the middle of the humerus, the patella, and the flat bones. At 
times they are caused by muscular action. 

(c) Oblique. This variety is characterized by a single or double 
line of fracture, making an angle with the long axis of the bone ; which 
is neither that of a longitudinal nor that of a transverse fracture. The 
majority of fractures are oblique. It is most commonly observed in 
fractures of the shaft of the humerus, tibia and femur. Such fractures 
may be multiple. 




abode f g h i j 

Fig. 6. — Fractures considered in relation to the character and line of fracture: a, longitudinal frac- 
ture; b, transverse; c, oblique; d, spiral; e, subperiosteal; /, V-, T-, or Y-shaped; g, compression; h, 
comminuted; i, impacted; and./, crushing. 



(d) Spiral. In this variety the line of fracture is a prolonged 
oblique fracture encircling the entire circumference of the bone. It is 
produced by torsion, or twisting, when a part of the extremity is fixed. 
The tibia, humerus, and femur are most frequently involved. A sub- 
variety of this fracture is the third fragment fracture, which consists 
of a small third fragment being detached at the seat of fracture. This 
type of fracture is also seen in some types of oblique fracture. 

(c) Subperiosteal. This term is given to that form of fracture 
generally transverse in direction in which there is no separation of the 
fragments and the periosteum is not lacerated. Such lesions generally 
result from direct violence, and are most frequently seen in the tibia 
and radius and ulna. 

(/) V-, T-, or Y-shaped. These fractures are so named from the 
direction of the lines of fracture resembling the letters named; and are 
most frequently seen at the lower end of the humerus and the lower end 
of the femur. 



14 TREATISE OX FRACTURES 

i g) Compression. Compression fractures are those due to a driv- 
ing together of the cortical and spongy layers of bone as a result of 
condensing force. They are seen most frequently in the calcaneum, 
astragalus, and vertebra?, and result most frequently in falls from a 
height, when the patient lands on the soles of his feet. 

( h ) Comminuted. When there are not only two fragments, but 
the bone has been extensively splintered at the seat of fracture, the 
injury is termed a comminuted fracture. This form is seen most 
frequently in the long bones as a result of gunshot injuries or when the 
bones have sustained injuries from great forces or are brittle because of 
senile changes. 

(i) Impacted. This variety of fracture is the result of violent 
driving together of the two fragments, so that the fibres become en- 




PlC, 7. — Fractures considered in relation to 
the position of the fracture: a. upper end; 6, 
shaft; and c, lower end. 



tangled and immobility with fixation is present. It is seen chiefly in 
fractures at the neck of the femur, lower end of the radius, and the 
cervical neck of the humerus 

(;) Crushing. This variety of fracture is seen as a result of direct 
violence, a- when a heavy body, like the wheel of a wagon, passes over 
the foot. It is a form of comminuted fracture. It is found most fre- 
quently in the carpal or tarsal bones, and differs from the compre-inn 
fracture in that the latter is the result of indirect violence, as a rule. 
while the former i- due entirely to direct violence. 

D. Fractures considered in relation to the position of fracture 
7 I : Fractures are generally referred to as involving certain por- 
tion- of a bone, such a- fracture of the shaft, fracture of the upper or 
lower end- of a bone : fractures of certain parts of the shaft, as fracture 
middle of the -haft of the femur: fracture of certain promi- 
nence-. Mich a- fracture of condyle-, or apophysis. 

/:'. Fractures involving a joint or articular fractures are those 



GENERAL CONSIDERATIONS 15 

fractures in which the joint surface is involved in the line of break 
(Fig. 8). They comprise three classes: (i) Intra-articular fractures 
in which the line of fracture is entirely within the joint; (2) para- 
articular fractures in which the line of fracture is near the joint, so that 
subsequent healing may directly interfere with joint functions, and 
(3) true articular fractures in which the line of fracture involves both 
intra- and extra-articular bone. All of these fractures may vary from 
a simple fissure with no laceration of the capsule to an extensive com- 
minuted fracture with extensive lacerations of the capsule. The most 
common type of articular fractures are those of the neck of the femur, 
of the lower articular end of the humerus, of the lower end or the head 
and neck of the radius, fracture about the ankle-joint, and fracture of 
patella and of the olecranon. 

F. Epiphyseal separations: These consist in a partial or complete 
separation of the epiphysis from the diaphysis before the time when 





iber of fragments; a, multiple fracture, and 6, 

ossification takes place in the epiphyseal cartilage. In females the last 
epiphysis unites about the twenty-third and in males about the twenty- 
fifth year. The epiphyses most frequently involved are lower epi- 
physes of femur, radius and humerus, and the upper epiphysis of 
humerus. In epiphyseal separations there is generally a portion of the 
diaphysis carried away with the epiphysis. The injury is usually the 
result of excessive strain upon the articular ligaments. There is always 
the possibility of arrest of growth in the bone affected, due to faulty 
replacement of the epiphysis or to premature ossification of the 
epiphyseal cartilage. 

G. Fractures considered in relation to the number of fragments: 
In contra-distinction to the varieties of fracture which presuppose that 
the break is limited to or radiates from one point, there are multiple 
fractures (Fig. 9, a). This term is applied to fracture of two or more 
bones, and sometimes to more than two non-communicating lines of 
fracture in a. single bone. Fractures occurring in two adjacent bones, 
like the ulna and fibula, are not designated as multiple fractures. The 
term double fracture (Fig. 9, b) is applied to two unconnected lines of 



16 



TREATISE OX FRACTURES 



fracture occurring in the same bone. Multiple fractures are usually 

the result oi direct external violence, and frequently the force is very 

Fractures oi this variety are often troublesome to treat satis- 

rily, localise of the difficulty of enforcing quiet upon the patient. 

There may be. in addition, considerable destruction of the overlying 

a account of the degree of the violence sustained at the 

time oi injury. 

Displacement of Fragments. — The relative position of the frag- 
ments of a broken bone gives rise to several forms of displacement. 
While the classification of Malgaigne has been, as a rule, adopted in 
_ displacement of fragments, it should be realized that dis- 
placements are generally a combination of two forms of displacement. 
rule it is the distal fragment which occupies the abnormal position. 





a » d _g_ / 

- of displaceme-- 
t, impaction or crushing; and/, diastas., (ration. 

Transverse fracture of the olecranon and patella are exceptions to this 
rule. In comminuted fractures the displacement is too complex in 
nature t-. permit of classification. 

Varieties of Displacement , Fig. to).— The tonus of displacement 
may l>e class 

ular displacement, or tilting, in which the axes of the 
• nn an obtuse angle. This form of displacement is most 
commonly seen in .^reen-stick fractures 

placement, consisting in rotati< >n i >f one fragment on 

- in relati. »n V 1 the - »ther fragment. The rotating fragment 

rally the distal, or lower, the fixed fragment is the proximal 

or upper, i me. The best example « >f this type of displacement is seen in 

tracture of the neck or shaft of the femur. 

a deviation of the frag- 



GENERAL CONSIDERATIONS 17 

ments anteroposteriorly or laterally or a combination of the two. This 
form is very rare, and is seen generally in combination with some other 
form of displacement. The us jal position of this form is in transverse 
fracture of femur or humerus. 

(4) Longitudinal displacement is a change in the length of the bone. 
Overlapping of the fragments is the common displacement. It is gen- 
erally combined with other varieties of displacement, and is most com- 
mon in oblique and spiral fractures. Separation of fragments occurs 
in fractures of patella and olecranon. 

(5) Impaction or crushing displacements consist in the penetration 
of a broad fragment by a narrow one (impaction) or in the destruc- 
tion of the osseous structure into small pieces (crushing). Impaction 
displacement is usually accompanied by rotary displacement, and is 
most common in fractures of the neck or through the trochanters of 
the femur, fractures of the upper end of the tibia, and of the lower 
end of the radius. Crushing displacements are most commonly seen in 
fractures of the tarsal bones. 

(6) Diastasis should be applied only to epiphyseal separations. It 
is sometimes used for a separation of the fragments of the bone in 
fractures such as occur in breaks of the patella and olecranon. 

Fractures in Which No Displacement Occurs. — In some varieties 
of fracture there is no displacement of the fragments. This may 
be due to (1) incompleteness of the line of fracture, as in fissure 
fracture ; ( 2 ) to the fragments being held together by the surround- 
ing periosteum and muscles, and occasionally by a parallel bone, as in 
subperiosteal fractures and fractures of the forearm and of the fibula; 
and (3) to the support of surrounding ligaments, as in some fractures 
of the patella and olecranon. 

Etiology of Displacement of Fragments. — Displacement of frag- 
ments is due to several causes. The chief are the fracturing force 
and muscular contraction. CEdema and infiltration of the soft parts, 
and muscular spasm keep up deformity. Muscular action in nearly 
every instance causes shortening, excepting in fractures of the patella, 
olecranon, and separation of epiphyses and apophyses. In these frac- 
tures the longitudinal deviation consists generally in separation of the 
pieces of bone. This is due to the powerful muscular attachments to 
one of the fragments. It is not always possible to predict the character 
and extent of displacement that will occur in a fracture at a given 
locality, for it depends on the direction and nature of the line of frac- 
ture as well as on the muscular attachments. Displacements occur 
more frequently and in greater variety in oblique and spiral fractures 
and less frequently in transverse fractures. 

Symptomatology. — The examination of every case of suspected 
fracture should proceed in a systematic manner. A careful history of 
2 



IS TREATISE OX FRACTURES 

the accident, its nature and time should be first obtained. The previous 
history should be noted, and the possibility of a pathologic fracture and 
of deformities from previous injuries should be remembered. The 
patient should be examined as soon as possible after the receipt of the 
injury, unless there is marked shock present. In this way one may 
often detect fractures more readily, because swelling and ecchymosis 
and spasm of the muscles have not taken place. If. however, there is 
considerable shock present, it is advisable to defer examination until it 
has passed. 

All clothing that may interfere with a careful examination of the 
part should l>e removed. It is also advisable to remove the clothing 
from the same part of the opposite side, so that the anatomical land- 
marks of the uninjured and injured sides may be carefully compared. 
This simple expedient will enable the surgeon to make a proper exam- 
ination and help him arrive at an accurate diagnosis. 

In many cases it is advisable to use a general anaesthetic, so that a 
thorough examination may not be prevented by reason of pain and 
muscular spasm. In children this is especially true, and anaesthesia is 
frequently required. At the same time reduction and immobilization 
may be performed. 

The symptoms produced by a recent fracture may be divided into 
two classes : objective symptoms and subjective symptoms. The 
objective symptoms are deformity, abnormal mobility of the part, 
crepitus, and oedema and ecchymosis. The subjective symptoms are 
pain and tenderness, loss of function or impaired motion, intermittent 
muscular spasm. 

Deform it v. — This is principally due to the displacement of frag- 
ments. Deformity is not always present. Fissure fractures and some 
impacted fractures give little if any deformity. Deformity is deter- 
mined by inspection, palpation, and measurements of the parts. It is 
the result of several factors. These are, the fracturing-force, the 
weight of the distal portions of the limb, the pull exerted by certain 
groups of muscles, and the oedema and ecchymosis infiltrating the soft 
parts alx.ut the seat of fracture. 

In many cases inspection will show the presence and site of fract- 
ure, which are confirmed by palpation. The non-injured side or sym- 
metric part should always be examined and compared with the injured 
part. In considering the degree or existence of deformity, previous 
fractures and injuries should Ik- taken into account, as well as exos- 
periosteal nodes, and shortening from chronic inflammatory con- 
dition- of joints and contracted tendons. The recurrence of deformity 
when restraining forces are relaxed is often a distinguishing charac- 
teristic of fracture and serves to differentiate it from dislocation. 
ul and repeated measurements from fixed bony points should 



GENERAL CONSIDERATIONS 19 

always be made. This is only reliable in estimating shortening when 
the two sides are placed in the same relative positions ; and then there 
is always some element of doubt if the subject is obese or there is 
moderate deformity or cedema. It should always be remembered that 
often there is an inequality in the length of the normal bones of the 
two halves of the body. This at times has been found to be from one 
to one and a half inches in the lower extremities. This asymmetry of 
uninjured long bones of the upper and lower extremities has an impor- 
tant bearing in medico-legal cases. Its relation to the prognosis in 
fracture treatment is readily seen. 

Abnormal Mobility of the Part. — This is absolute proof of a 
fracture, excepting in very extensive dislocations. Abnormal mobility 
is sought by endeavoring to move one portion of the bone independently 
of the other. In doing this one may produce one or more of the 
various types of displacement. Absence of mobility must not be 
assumed until all forms of displacement have been attempted, as it is 
likely that displacement may be possible only in certain directions. 
Abnormal mobility is absent in incomplete, subperiosteal, and impacted 
fractures and occasionally in fractures involving joint surfaces. When 
one of two bones is broken the abnormal mobility may be slight. In 
some fractures the normal elasticity of the part or the proximity of a 
joint may simulate abnormal mobility and mislead the examiner. Error 
may thus occur in injuries of the sternum, ribs and fibula ; in hurts 
near joints, because, there, motion is the normal condition ; and in 
fractures in which the fragments are so small or deep-seated that they 
cannot be firmly grasped. This diagnostic difficulty is observed often 
in fractures of the surgical neck of the humerus, metatarsal fractures, 
and in atypical fractures of the upper end of the femur. 

Abnormal mobility may be readily demonstrated in the shaft of a 
bone broken near its middle by placing the hand under the part at the 
supposed seat of fracture and endeavoring to raise it with this single 
point of support. Motion and angular displacement immediately re- 
sult. It may also be determined in some cases by placing a finger of 
each hand upon the supposed upper and lower portions of a small 
fragment and producing a rocking motion. This ma)' be seen in 
fractures involving the lower two inches of the fibula or of the ribs. 

Crepitus. — This is a rubbing sensation, conveyed to the examiner's 
hand, and is produced by forcible manipulation of the parts. The 
motion may give rise to a grating sound audible to the bystanders. In 
order that crepitus may be produced, certain factors are necessary. 
The ends of the fragments must be in apposition or capable of being 
brought into ; apposition by the surgeon or a third person, causing 
traction when manipulation is made. It is absent in impacted, green- 
stick, and incomplete fractures. It cannot be produced if the ends of 



20 TREATISE ON FRACTURES 

the fragments are separated, as in fractures of the olecranon and 
patella, if there is marked over-riding so that smooth portions of the 
bone are in apposition, or if portions of muscle, fascia, ligament, or 
other structures intervene. In old fractures, when the ends of the 
fragments have become covered with fibrous tissue, and in delayed 
union of fractures or pseudo-arthroses true crepitus is no longer to be 
elicited. 

Fracture crepitus may be confounded with joint crepitus, with the 
fine crackling noted in inflammatory conditions of tendon sheaths and 
bursa-, and with various sounds resulting from cellular emphysema 
and pleuritic adhesions. The crepitus made upon manipulation may be 
discernible to the patient. It can often be distinguished by placing the 
palm of the hand over the seat of the injury, as in fracture of the ribs. 

(Edema ok Swelling. — This can hardly be classified as a distinct 
symptom of fracture because subcutaneous pouring out of blood and 
serum occurs in all severe injuries, yet it occurs so frequently with 
any forms of fracture that its importance should not be neglected. 
This serous or bloody swelling may be rapid and appear not only as 
generalized infiltration of the soft tissues surrounding the fracture, but 
may be shown by blebs or small vesicles occurring on the surface. 
These are filled with turbid or bloody serum. 

Ecchymosis. — Bleeding into the interstices of the tissues, as a 
result of contusion of the soft parts overlying the broken bone, 
occurs within the first twenty-four hours. Ecchymosis appearing 
after the lapse of several days indicates that the blood has escaped 
from deep structures. This may begin to show after the first twenty- 
four hours, or may not be seen for four to five days. It is generally 
indicative of a fracture. The time of its appearance is due to the 
difficulty of reaching the surface through periosteum, muscles, and 
fascia. It may occur at a distance from the seat of fracture and 
shows in a dependent part of the body or limb, which it reaches by 
gravity. Very often ecchymosis is accompanied by the occurrence 
of blebs, and in some cases the parts may be so badly discolored as 
to lead the inexperienced to diagnose gangrene of the part. The 
absorption of the blood is generally very tardy, and the fracture may 
be firmly united before the final disappearance of the extravasation. 

Pain and Tenderness.— Pain is a usual symptom in fractures. 
It varies greatly in severity. In fissured, incomplete, or impacted 
fracture pain may be slight. Tain is -real- in fractures involving a 
single supporting bone of a part, and in those in which a nerve is 
caught bet wren the fragments or pressed upon by infiltration of the 
soft part- or by callus. Pain as a rule is not great when the fragments 
an- separated. Tenderness is noted particularly in fractures produced 
by direct violence. It is of diagnostic value in differentiatino- ol> 



GENERAL CONSIDERATIONS 21 

scure fractures from contusions and sprains, and in determining the 
seat of the lesion in periosteal fractures, sprain fractures, in fractures 
of the carpal bones, and in deep-seated fractures. 

Loss of Function. — In the presence of fractures this may be 
the result of pain, or it may be due to the loss of continuity in the 
bone. Motions which do not give pain at the seat of fracture and 
which may be performed by reason of a supporting parallel bone may 
be accomplished in many cases. This is particularly so in fractures 
in which certain motions do not bring stress at the seat of fracture. 
Loss of function may be absent in incomplete, partial, and impacted 
fractures. It is a common occurrence to see patients walking around 
with fracture of the lower end of the fibula, and sometimes even of the 
upper end of the femur. 

Intermittent Muscular Spasms. — These are often present and 
may cause great pain. They result from stimulation produced by 
excitation of terminal nerve filaments in the muscles about the seat 
of fracture. Numbness and occasionally complete paralysis may be 
present as a result of pressure upon a nerve or complete destruction of 
a nerve, either at the time of injury or by subsequent pressure of the 
fragments or by callus. 

The constitutional symptoms of fracture are those of shock or 
of a subsequent inflammatory process. In the usual closed fracture 
constitutional symptoms are generally slight. There may be a slight 
rise of temperature noted during the first three to four days. In open 
fractures the constitutional symptoms are those that occur as a result 
of the complications of open fractures. In old age the constitutional 
symptoms are liable to be more marked, and fractures may have serious 
terminations from sequellas in the senile that are rare in the young. 

Diagnosis. — In suspected fracture the diagnosis may often be 
readily made ; but there are cases in which one or several of the 
cardinal symptoms of fracture are lacking, and therefore the diagnosis 
may be extremely difficult. In these instances careful examination 
should be made under general anaesthesia and comparison made with 
the opposite symmetrical parts. 

Diagnosis is difficult in fractures near joints. The chief causes are 
normal mobility present at a joint, the difficulty of thoroughly grasp- 
ing the small fragments so as to elicit the objective signs of fracture, 
and joint crepitus. The most characteristic signs of articular fracture 
are effusion into the joint, generally bloody in nature, and mobility 
greater than that found normally at the involved articulation. 

Dislocations may be confused with fractures near joints ; but in 
dislocations the normal motions of the articulation are impaired, and 
there is generally a sudden or abnormal check to free movement in 
some directions on manipulation by the examiner. In fractures the 



22 TREATISE ON FRACTURES 

movements are generally preternatural ; they may be unlimited. Spon- 
taneous recurrence after reduction of dislocations is very infrequent, 
while in fractures deformity is liable to be reproduced when fixation 
is removed. In dislocations, voluntary motions are not so impaired 
as in fractures, and there is more rigidity, while in fractures there is 
the appearance of helplessness. In dislocations, specific positions of 
the part are impossible on account of the change in bearing points 
of the articulation, and the relations of the normal bony landmarks of 
the joints are changed. 

Fractures may be differentiated from epiphyseal separations by 
noting the site of the suspected fracture, by considering the age of 
the patient, by the character of the crepitus, which is soft and more 
indistinct than in fractures, by the tendency toward slight displace- 
ment, and by the localization of the abnormal mobility and pain at 
the level of the epiphyseal cartilage. Separations of epiphyses are 
often followed by diminished growth in the length of the bone due to 
the involvement of the epiphyseal cartilage. Epiphyseal separations 
arc generally accompanied by a fracture of the meta-epiphyseal end 
of the diaphysis, and rarely by a splitting of the epiphysis. 

At times it is difficult to determine the exact location and line of 
fracture. This very important information may usually be determined 
by careful palpation, measurements from known fixed points, and the 
position of various related prominences. Often the exact line of the 
break can only be inferred unless X-ray examinations are made in two 
planes. In fractures without deformity or crepitus the localized pain 
and tenderness present may enable the line of break to be recognized 
with reasonable probability. 

.Many fractures are overlooked at the time of injury and are only 
discovered afterward by the presence of callus, or by the persistence 
of pain and tenderness, or by loss of function of the part. This error 
occurs in fractures of the ribs, metacarpals, carpals, tarsals, sternum, 
and forearm; and in incomplete, subperiosteal, impacted, and sprain 
fractures. Many of the symptoms of fracture may be absent in these 
injuries. 

Rontgen Rays in the Diagnosis of Fractures. — The use of the 
Rontgen rays in the diagnosis of fracture and injuries to joints is 
of great value. They not only show the line of fracture but also the 
number and relation of fragments. An exception to this, however, is 
their use in certain types of early epiphyseal separations. The Rontgen 
rays, however, should not he employed to the exclusion of other means 
of diagnosis. They are of especial value in deep-seated fractures, in 
fracture near joints, in fractures of the carpal and tarsal bones, in 
sprain fractures, and evulsion fractures. Careful examination and 
skilled interpretation of the X-ray plate should be painstakingly made. 



GENERAL CONSIDERATIONS 23 

One should first familiarize himself with the X-ray photographs of 
the normal bone, and especially with the articular portions. 

If there is an X-ray equipment at hand, it should be used routinely 
in the study of all suspected fractures. Only by this use of the 
X-ray will a surgeon become familiar with the normal parts. He 
will also make many more correct diagnoses of obscure injuries, and 
he will be better able to make diagnoses in fractures from previous 
knowledge gained in X-ray plate interpretation when an X-ray ex- 
amination is not feasible. Routine fluoroscopic examination is prob- 
ably not advisable. While it is useful in gross fractures, it does not 
show small obscure lesions, unless one is carefully trained in its use. 
The necessary repetition of fluoroscopic examinations is dangerous 
to the examiner. A primary X-ray negative before reduction if 
feasible should be taken ; another after reduction is desirable. 

In some cases repeated X-ray negatives should be made at intervals 
of five days to a week, so as to note the position of the fragments. 
Many errors of interpretation are possible. The shadow produced on 
the X-ray negative is the result of different opacities of the parts rayed. 
Distortion of the parts, incorrect adjustments of the tube, the relative 
distance of the parts from the plate, the various angles of incident 
rays to the part, and the surrounding dressings tend toward error and 
misinterpretation of the plate. When possible two negatives of the 
bone should be made in planes at a right angle. 

It is only by great care in the taking of X-ray negatives, by long 
practice in the interpretation of the plates, and by the combination of 
findings from this source with those from clinical examination of the 
injured parts that the Rontgen ray can become of greatest service in 
the diagnosis of fractures. 

Repair of Fractures. — Repair in Recent Closed Fractures. — 
The repair of fractures does not differ materially from the repair 
which takes place in other tissues. The variation in the process of 
repair depends generally upon two factors : ( i ) proper anatomical 
apposition of the fragments; and (2) the proper nutrition of both 
fragments. Less callus is formed, union is more prompt, and dis- 
ability less when perfect anatomical apposition is obtained and main- 
tained. On the other hand, if the fragments are not placed in perfect 
apposition and so maintained, there is more irritation at the ends of 
the fragments, which causes an increased amount of exudation and 
callus. Union may be delayed or arrested, if the fragments are not 
maintained in place ; or it may be obtained only by a great production 
of callus, such as is seen at times in fractures occurring among the 
insane. When one fragment has deficient or no blood supply, repair 
may be arrested and at times ceases. 

Repair in fractures is carried on by two structures, the periosteum 
and the medulla, furnishing an osteogenetic bond or callus. 



24 TREATISE ON FRACTURES 

At the moment of injury there is more or less tearing and bruis- 
ing of the periosteum, with rupture of blood-vessels of the periosteum 
and of the bone. The immediate result is interstitial hemorrhage, with 
effusion of fluid and an infiltration of leucocytes in the surrounding 
structures. This infiltration continues about four to six days. At 
the end of forty-eight hours there is proliferation of the cells of the 
periosteum and medulla and this is soon accompanied by a like prolif- 
eration of the endothelial cells of the involved blood-vessels, so that at 
the end of the fourth day there is a definite osteoblastic tissue forma- 
tion. Microscopically this consists of large polymorphonuclear cells, 
many mitotic figures, and a fibroid stroma. This tissue is rapidly 
changed into chondroid and osteoid tissue which soon becomes bone. 

At the end of a week the ends of the bone are surrounded by a 
spindle-shaped sheath, made up of osteophytes, osteoid spicules, and 
fibroblastic stroma. This is called callus, and may be divided into 
three forms: periosteal, or ring callus, which is external to the bone 
and surrounds the seat of fracture; intermediary callus, which is a 
prolongation of the periosteal callus between the ends of the fractured 
bones; and myelogenic or internal callus, which extends a short 
distance up and down the medullary cavity of the shaft at the seat 
of fracture. Callus is also spoken of as provisional callus, consisting 
of bone produced in excess, and definite callus, which occurs between 
the ends of the bone and is permanent. The callus is produced by the 
osteoblasts, and later changes into osteoid and later into osseous tissue. 

With these changes are found blood-vessels extending into the 
callus, the process being similar to that seen in embryonal bone forma- 
tion. These vessels enter the callus from the periosteum, the endos- 
teum, and the fractured ends of the bones. As this process proceeds 
and vascularization is complete, the callus has been changed in places 
into hyaline cartilage and fibrous connective tissue. This is followed 
by the formation of bony lamellae about the blood-vessels, and the 
production of Haversian systems and true bone formation begins. In 
tbis maner the callus is slowly changed into dense bony tissue until the 
fragments are firmly joined and the process of union is complete. 
Coincident with this stage there begins an absorption of the periosteal 
and endosteal callus, which if not removed would often interfere with 
the function of the parts. This absorption is carried on by the activity 
of the osteoclasts. The process is one of months or years, depending 
upon the amount of excessive callus and the degree of deformity. It 
finally results in the removal of all excessive callus, both periosteal and 
myelogenic, and in the rounding off of all irregularities. Where there 
was at first an excessive amount of callus, there finally results a sym- 
metrical bone. In some fractures in which very little displacement of 
fragments occurs, the process may be so perfect that it may be im- 



GENERAL CONSIDERATIONS 25 

possible to determine the seat of fracture, and a longitudinal section of 
the bone will show a continuous marrow cavity. 

The size of the callus depends upon the extent of the fracture and 
the displacement of the fragments. Comminuted fractures associated 
with a great degree of separation of the fragments are followed by 
the production of exuberant or luxuriant callus. 

When the parallel bones of a part are fractured about the same 
location, the resulting callus may produce a bridge, causing synos- 
tosis of the two bones. When fractures involve joint surfaces, exub- 
erant callus generally results, unless perfect anatomical apposition is 
made, and ankylosis may thus take place. 

In articular fractures the fragments are displaced by the effusion 
into the joints, by the violence causing the fracture, and by the pull of 
certain muscles. In this class of fractures union occurs entirely from 
the myelogenic and intermediate callus, as there is no periosteum cov- 
ering an articular surface. Unless accurate apposition of the frag- 
ments is obtained, there is generally a production of exuberant callus. 
This may interfere with normal joint motion by changing the contour 
of the joint surfaces and thus limiting motion. 

In epiphyseal separation repair proceeds in the same manner as in 
fractures. There is, however, very little callus formed, and as a gen- 
eral rule little if any interference with the epiphyseal cartilage. Sub- 
sequently early ossification of this cartilage may materially interfere 
with the growth of the bone. This condition is rarely seen. 

Repair in Recent Open Fractures. — The process of repair in 
open fractures is the same as in closed fractures, if there is no infection 
and the fracture is soon converted into a closed one. When infection 
takes place the process of repair is greatly prolonged, and in some 
cases occurs only after great destruction of bone. There are many 
stages to the process, depending upon the nature of the infection and 
whether the periosteum alone is involved, or the medullary cavity also 
infected. If only the periosteum is involved in septic infection, osteo- 
genic function depends entirely upon the bone and endosteum. Gen- 
erally when an open fracture becomes infected there are the early 
stages of polynuclear infiltration and phagocytosis, after which callus 
formation takes place, accompanied by the discharge of particles of 
necrotic bone until subsequent healing occurs. In these cases the 
callus is more extensive and its various stages of ossification are 
greatly prolonged. 

Repair in recent aseptic closed fractures treated by aseptic opera- 
tion is identical with the stages seen in closed fractures not operated 
upon. The only difference is that probably the time of repair is some- 
what lengthened, and at times the foreign bodies used in direct 
fixation of the fragments cause some irritation of the wound. This 



26 TREATISE OX FRACTURES 

produces a discharging sinus from the seat of fracture, with result- 
ing localized caries. Removal of the plate or other means of fixation 
is, as a rule, promptly followed by closure of the wound. In fractures 
subjected to direct fixation requiring removal of a non-absorbable 
means of fixation, there is often some degree of infection present. 
The infecting agent has gained admission to the wound at the time of 
the operation, or subsequently through the stitch holes, or perhaps 
from the blood current, because the site of fracture is a place of 
lowered resistance. 

Delayed Union, Non-union, Vicious Union. — The length of time 
for union to take place varies with different bones, and at different 
periods of life. Union takes place in the phalanges and metacarpals 
in about two to three weeks: about three to four weeks in fractures of 
the ribs and bones of the forearm ; five to six weeks for fractures of 




Fig. ii. — Rontgenogram showing pseudarthrosis of radius and ulna (see Fig. 12). 

the humerus and bones of the leg; seven to ten weeks for fractures of 
the femur. Fractures of the neck of the femur take even longer. 
While we generally consider that union is firm in these bones in the 
time specified, the Rontgen ray has shown that the reparative process 
is not complete for a much longer time. Repair takes place more 
rapidly in children and the healthy than in the aged and infirm. Even 
at the end of the times mentioned the union is not firm enough to bear 
unusual stress or strain. This is particularly true as to die weight 
bearing of the lower extremities. 

Delayed Union.— A fracture is classed as one of delayed union 
when there remains a degree of mobility and pain on motion after the 
usual time for consolidation has elapsed. Delayed union is generally 
the result of deteriorated health, and consolidation as a rule is secured 
by improving the general health and increasing local congestion by 
and hot-water bathing. 



GENERAL CONSIDERATIONS 27 

Non-union. — A fracture is classified as ununited when the rigidity 
of union has not resulted after the usual means have been employed to 
obtain union for a much longer time than is customarily needed. It is 
a rare condition and occurs in the presence of definite bone disease, 
such as necrosis, sarcoma, osteomalacia and carcinoma, when the frag- 
ments are not in good apposition, or where the patient's general con- 
dition is so weakened that callus formation has not occurred. Failure 
of union may also be due to the interposition of soft parts, to poor 
blood supply, to infection, and to wide separation of the fragments, as 
in some fractures of the olecranon and patella, faulty immobilization, 
and muscular action. A fibrous union is the general sequence of such 
conditions. The ends of the fragments are found to be rounded, the 
medullary cavity is closed, and a moderate degree of exuberant callus 
and fibrous tissue surround the area of the ends of the fragments. 




Fig. 12. — Photograph of false joint or pseudoarthrosis following open racture of radius and ulna, 
operated upon twice (see Fig. n). 

This condition is known as pseudarthrosis (Figs, n and 12). True 
joint formation is rare at the seat of an old fracture ; but sometimes a 
serous bursa is developed between the fragments. The most fre- 
quent seats of non-union are the shafts of the humerus and femur, 
the patella, the olecranon, and the neck of the femur. 

Vicious Union (Fig. 13). — This term is used to describe union 
of fragments in marked deformity. The deformity may be shortening 
from impaction and over-riding; shortening combined with rotation 
of the distal fragment; angularity at the seat of fracture; limita- 
tion of motion due to exuberant callus and changes in the normal 
relation of the joint surfaces. The term is also used to designate that 
union which takes place with the formation of exuberant callus and 
the inclusion in the callus of nerves, blood-vessels, muscles and tendons. 
The causes of vicious union are imperfect reduction of the fracture 
and imperfect or faulty methods of immobilization of the fragments. 
Vicious union is seen most frequently in fractures of the clavicle, of 



28 TREATISE ON FRACTURES 

the lower end of the humerus, of the lower end of the radius, of the 
upper end, shaft, and lower end of the femur, of the shaft of the 
tibia, and in fractures about the ankle-joint. 

Infection in Fractures. — Infection of the seat of fracture may be 
due to several conditions. In closed fractures infection may occur 
through the blood stream. Infection occurring in this manner is 
generally in fractures at the lower ends of the tones or near the epi- 
physeal line, and is due to the lodgment of bacteria in the terminal 
vessels at this point. The condition is rare and sometimes occurs and 
presents all the symptoms of an acute osteomyelitis in addition of those 
of fracture. Diagnosis is difficult, and one should not be too hasty in 
making a positive diagnosis. In addition to the local signs, there is 
marked elevation of temperature, leucocytosis, and a marked increase 
in the polymorphonuclear percentage. Primary infection may take 
place at the seat of fracture through wounds of the soft parts over- 




Fig. 13. — Vicious union. Femur, fracture of shaft, junction of middle and lower thirds. Union has 
occurred with marked over-riding, angulation, and outward rotation of the lower fragment. (Wistar 
Institute of Anatomy.) 

lying the fracture. If the wound leads down to the site of fracture 
the injury is called an open fracture. In open fractures infection 
occurs generally at the time of injury. Secondary infection may occur 
from sloughing of the soft tissues overlying a closed fracture. In- 
fection also may occur in closed fractures through an operation wound 
made in applying a direct fixation apparatus. 

Complications of Fractures. — The complications of fractures may 
be classified under the following headings : 

1. Lesions of the Overlying Soft Parts.- — These consist of 
contusions, lacerations, perforations by sharp fragments, and slough- 
ing; bullae and blebs and. occasionally, gangrene from pressure of 
exudate or of fragments : and later as sequels of a fracture there may 
be disturbances of nutrition shown by interference with the growth 
of the nails and hair, and the occurrence of eczema or other trophic 
changes in the skin. 

2. Injury to Important Arteries and Veins. — These may 
complicate either a closed or an open fracture. The vessels are in- 



GENERAL CONSIDERATIONS 29 

jured by pressure, by laceration, or by puncture. This complication 
is rare, and when it does occur is very serious. The fractures most 
frequently seen complicated by injury to arteries and veins are those 
of the skull (middle meningeal artery), the clavicle (subclavian artery 
or vein), the humerus (Figs. 14, 15, and 16) (brachial or axillary 
artery or vein), ribs (intercostal artery), innominate bone (internal 
iliac artery or vein ) , femur ( femoral or popliteal vessels ) , and tibia 
(anterior tibial artery). The results of injuries to arteries or veins 
are marked, even fatal, hemorrhage, when the bleeding occurs into a 
large cavity ; and traumatic or false aneurism, or gangrene, when the 
blood escapes into the tissues surrounding the wounded vessel. 




Fig. 14. — Rontgenogram showing diacondylar fracture of humerus (see Figs, is and 16). 

The symptoms of internal hemorrhage are rapidly increasing 
anaemia, rapid weak pulse, failing blood-pressure, pallor of the skin, 
thirst, sighing respiration, restlessness, collapse, and the physical signs 
of an abnormal accumulation of fluid in a cavity. 

The symptoms caused by a massive extravasation, the so-called 
false aneurism, are a swelling, gradually increasing in size, which later 
may pulsate; absence of pulsation in the vessel distal to the injury, 
with coldness and anaemia of the extremity, and the presence of a 
murmur synchronous with the pulse. Laceration or puncture of a vein 
results in extensive ecchymosis and swelling, which later may, by com- 
pression of the vein, produce gangrene of the extremity below. Lacera- 
tion of both artery and vein results in absence of pulse below, marked 
oedema of the part, dilatation of the superficial vessels, and signs of a 
large hematoma if gangrene does not occur. 



30 



TREATISE OX FRACTURES 



The treatment of laceration or puncture of important arteries or 
veins consists in immediate exposure of the injured vessel under 
aseptic precautions and resection with end-to-end anastomosis, or. if 
the laceration is small, suture of the opening in the vessel. In danger- 
ous pressure from blood or exudate without injury to a large vessel 
wall, immediate incisions of skin and deep fascia may prevent the 
occurrence of gangrene or vascular thrombosis. If thrombosis has 
already occurred, the vessel should be opened, the clot removed, and 
the opening in the vessel wall closed with suture. If the thrombus is 
attached to an area of damaged vessel wall, this should be resected, if 

i 




■ 



■M 



Fig. i 6. 
Figs. 15 akd 16.— Moist gangrene of hand and part r! forearm due to diacondvlar fra 
ry. Case required 

le, and the ends approximated by Carrell's method 
• The fragments of bone in most of these cases should be fixed 
in apposition, if possible, by a steel plate or other device for prevent- 
ing motion. 

3. Injuries to Important Nerves. — Recent injuries to nerves 
complicating fractures are contusion, stretching, compression, lacera- 
and complete division. Late nerve lesions result from com- 
pression between fragments of bone, or inclusion in callus or cica- 
tricial • 

The fractures in which nerve injury is most frequent are :' 



GENERAL CONSIDERATIONS 31 

the clavicle (brachial plexus), humerus (musculospiral, circumflex, 
and median), lower end of humerus (ulnar), radius (radial), femur 
(sciatic), tibia and fibula (peroneal). The symptoms of nerve in- 
jury are loss of power, loss of sensation, trophic and vasomotor 
changes, and changes in electrical reaction. The late symptoms are 
muscular wasting, cicatrices from trophic ulcers, contractures, and the 
presence of a neuroma at the end of the severed nerve. 




Fig. 17. — Ischemic muscular atrophy (Volkmann's contracture.) (Courtesy of Dr. G. G. Davis.) 

The treatment of nerve injuries associated with fractures consists 
of exposure of the ends of the severed nerve and their union by suture 
with silk. It is advisable to surround the site of nerve suture with a 
piece of a freshly excised vein. This prevents the formation of a 
cicatrix of fibrous tissue between the ends of the severed nerve. In 
cases where the nerve is inclosed by callus or compressed between 




■operation. (Courtesy of Dr. G. G. D: 



fragments, the callus or bone should be cut away until the nerve is 
freed from pressure. 

4. Injury to the Muscular System. — The muscles of the part 
in which a fracture has occurred primarily undergo oedema and later 
atrophy from disuse. This condition rapidly disappears in the young 
with subsequent use, but it may be more or less permanent in the aged 
or in those fractures in which the functional result is poor. The 



32 TREATISE ON FRACTURES 

coincident damage to muscles, tendons, and fascial sheaths in all 
fractures is often neglected by surgeons. It may be of as much im- 
portance as the lesion of the bone itself. Atrophy, adhesions, and loss 
of function may result from the damage to the muscular structures. 
Massage from the beginning of treatment may be of great value. The 
massage must be light. Early mobilization is often valuable. 

A most important secondary complication of fracture is the change 
which occasionally takes place in the muscles of the part, called Volk- 
mann's contracture (Figs. 17, 18, 19, and 20). This condition, termed 
ischemic atrophy, is most frequently seen involving the forearm, after 




Fig. 19. — Before operation. Ischemic muscular atrophy. 
Fig. 20.— After operation. (Courtesy of Dr. G. G. Davis) 

fractures of the humerus, or of the radius or ulna. The change is a 
dense infiltration of the muscles, followed quickly by a rapid degen- 
eration of the muscle fibres, which is irregular in distribution. Asso- 
ciated changes occur in the nerves of the part, which are found to be 
degenerated. The cause of the condition is probably undue constric- 
tion and interference with the circulation, resulting from a too tight 
application of splints, perhaps improperly padded, too tight bandag- 
ing, or to the prolonged use of the tourniquet. The symptoms are 
primary swelling of the part distal to the fracture, with marked 
•sis and flexion of the fingers without any great pain. Removal 



GENERAL CONSIDERATIONS 33 

of the splints in twenty- four hours shows localized necrosis, generally 
on the flexor and extensor surfaces of the forearm and the wrist. 
Marked contracture of the muscles takes place with involvement of 
tendons and nerves, so that the final picture is one of marked atrophy 
and shortening of the muscles, contractures, loss of sensation at times, 
and loss of muscular power. Flexion at the wrist and at the phalangal 
joints is marked. 

The preventive treatment of this condition is early removal of 
all constriction and massage of the part. Later these measures are 
unavailing and the deformity above described results. Operative 
treatment of the disabled limb consists in dissecting out the tendons 
and muscles with lengthening of the same, followed by massage and 
passive motion. Nerve resection and anastomosis of muscles and 
nerves may occasionally be of some benefit. Resection for the pur- 
pose of shortening both radius and ulna has been suggested for this 
condition, but its usefulness as an operative procedure is doubtful. 
Mechanical devices are at times necessary to keep the fingers in proper 
position, and at times are useful for maintaining partial function. 

5. Injury to a Neighboring Joint. — At times neighboring 
joints are directly involved in the line of a fracture; and, aside from 
those fractures which involve the articular surface, there is often seen 
marked stiffness and cedema of the neighboring joints when the articu- 
lar end of the bone is not broken. This complication is seen most 
frequently in the infirm, the old, and those with a rheumatic tendency. 
In fractures involving the joint surface, there may result a marked 
traumatic arthritis, with perhaps the formation of excessive callus. 
There then occurs not only stiffness and cedema, but also marked 
limitation of motion. This condition is very often permanent, and 
greatly limits the subsequent usefulness of the part. In many of these 
cases there is an atrophy of the muscles of the limb and a periarticular 
cedema with fixation of tendons, ligaments, and nerves in fibrous tis- 
sue, so that all the soft parts are involved in a general cicatrix. 

When the line of fracture involves the adjacent joint, there is 
generally seen a moderate degree of limitation of motion, unless the 
fragments are accurately adjusted; then callus formation is slight. 
The presence of intra-articular callus formation is due to malapposi- 
tion of the fragments. By the deformity and the deposit of callus, 
the joint surfaces are altered and the contour of bearing surfaces 
changed. The result can hardly fail to be limitation of motion. 

The treatment of these conditions consists in the accurate adjust- 
ment of the fragments primarily, persistent active and passive mo- 
tion, massage, and in those cases in which limitation of motion is 
due to serious malposition of fragments, operation. 
3 



34 TREATISE OX FRACTURES 

Association with an Adjacent Dislocation. — At times fracture 
may l>e complicated by a dislocation of an adjacent joint. The com- 
bination is seen most frequently in fractures of the surgical neck of the 
humerus associated with dislocation at the shoulder-joint, fracture of 
the glenoid cavity or neck of the scapula with dislocation at the 
shoulder-joint, fracture of the upper end of the ulna associated with 
dislocation of the head of the radius, fracture of the lower end of 
the radius with dislocation of the lower end of the ulna, fracture of 
the vertebrae with dislocation, fracture of the upper end of the femur 
with dislocation of its head, and fracture of the pelvis associated with 
dislocation at the hip-joint. 

The treatment of this condition may be non-operative or operative. 
Occasionally it is possible to reduce the dislocation by external manipu- 
lation, either before the fracture has been reduced or after the frag- 
ments have l^een replaced and immobilized. Generally, however, it is 
necessary to expose the seat of fracture by incision. Then after re- 
duction and immobilization of the fragments, it may be possible to 
reduce the dislocation. At times it is necessary to expose also the 
seat of dislocation in order to obtain reduction. Occasionally excision 
of the articular fragment may be necessary. 

A fracture may be associated with a previously unreduced dislo- 
cation or an ankvlosed joint. A\ 'hen there is present a previouslv 
unreduced dislocation complicating a recent fracture, the presence of 
the dislocation should be disregarded unless it may seem possible to 
reduce it and hold the parts in their normal position by operation. 
( ienerally, the articular changes present are of such a character as 
to preclude the possibility of improvement, short of a total excision 
of the joint. In fractures complicated by ankylosis of a neighbor- 
ing joint it will be most feasible to entirely disregard the presence 
of the ankylosis. It should, however, be borne in mind that extra 
precautions should be taken in immobilization, as this condition mav 
be followed by non-union or pseudo-arthrosis at the seat of fracture. 

Eat Embolism. — This is a condition often described in treatises 
on fracture- but is rarely seen, and when it does occur is usually 
followed by no alarming symptoms. It can readily be seen that in 
all fractures involving the bone-marrow there are almost necessarily 
small numbers of fat globules carried into the circulation. These fat 
globules may find their way to the brain, lungs, kidneys, or spleen. 
They differ, however, from the ordinary blood embolism in that the 
fat globules do not adhere to each other, and therefore usuallv do little 
harm except in terminal vessels of very small calibre. In the various 
organ- where they may lodge they may produce infarcts, oedema, or, 
in the lung, pneumonic area-. 

It is more common in closed than in open fractures, and mav some- 



GENERAL CONSIDERATIONS 35 

times give rise to grave symptoms. In the brain fat globules may- 
produce areas of cerebral softening. In the lung they may cause 
dyspnoea, cyanosis, and areas of dulness with rales ; in the kidneys they 
may produce fat globules in the urine, with casts and albuminuria. 

The treatment of the condition is entirely symptomatic. While 
the presence of fat globules in the circulation in cases of fracture is 
common, the fact of their producing any actual damage is question- 
able, and the cases of supposed death in cases of fracture, commonly 
ascribed to fat emboli, are very doubtful and open to question. A 
thorough autopsy on these cases would undoubtedly frequently show 
the cause of death to be other than fat emboli. 

Thrombosis and Embolism. — In fractures of the lower ex- 
tremity all the evidences of obstruction to the venous system may 
appear. This is particularly true in fractures of the bones of the leg, 
and is due to the formation of a thrombus, generally in the deep 
veins. This condition is rarely seen while the patient is at rest in bed, 
but generally is noticeable when the patient begins to be up and about. 
Then is seen a large, cedematous, bluish leg, resulting from obstruc- 
tion. In some instances emboli are detached from the venous thrombus 
and are carried through the heart to the lungs and there produce 
lesions varying from a localized bronchitis, localized consolidation 
with pleurisy, to sudden death. The symptoms of these conditions are 
totally different. All of them, however, occur, as a rule, several weeks 
after the injury, and sometimes after massage of the part. The onset 
is sudden and in cases of sudden death there may be extensive pallor 
or cyanosis, difficulty in breathing, shock, a weak, rapid pulse and a 
rapidly fatal issue. It is very suggestive of this condition when pa- 
tients develop the so-called hypostatic pneumonias in cases of fracture. 
In such instances it is always well to consider the possibility of pul- 
monary emboli. Thirty-six cases of pulmonary embolism after fract- 
ure are reported by Lotheissen, with 30 deaths. They all occurred in 
people past middle life, and 34 cases were closed fractures. The 
bones of the leg were fractured in 25 cases, the femur in 7 cases, the 
humerus in 3 cases and the patella in 1 case. Two cases were open, 
or compound, fractures. 

The preventive treatment of this condition is care in the splinting 
of the parts, careful massage and passive motion with proper stimu- 
lation to the arterial system. In the presence of embolism the treat- 
ment is purely symptomatic. The presence of extensive pulmonic 
emboli is generally fatal, as shown by the above statistics. 

Infection. — This condition is seen most frequently as a com- 
plication of open fractures. It is rarely seen in closed fractures. When 
it occurs in closed fractures the patients are apt to be children. The 
lesion begins generally in the epiphyseal end of the diaphysis. It 



30 TREATISE ON FRACTURES 

occurs here through deposit of bacteria in the terminal vessels at the 
epiphyseal line, and in addition to the symptoms of a fracture there 
arise symptoms of an acute osteomyelitis. 

The organisms found are, as a rule, the Streptococcus pyogenes, 
the Staphylococcus aureus and albus or a combined infection of the 
two. Occasionally a more virulent form of infection is seen. Of 
these may be mentioned the tetanus bacilli, the Bacillus aerogenes 
capsulatus, the bacillus of malignant oedema. In all cases of infection 
the severity of the local signs depends upon the nature of the organism, 
the extent and character of the wound, and the general powers of 
resistance. The chief symptoms are redness, oedema, and increased 
local heat, with the presence of a foul discharge from the wound, in 
addition to the general symptoms of infection, viz., increase in tem- 
perature, increased pulse rate, leucocytosis, and delirium. In the 
malignant forms of infection the symptoms are more severe. Rapid 
and extensive involvement of the affected bone occurs, and at times 
of the neighboring joints. Gangrene is rapid and saprsemia and 
septicaemia very pronounced. 

The treatment is antisepsis, and extensive drainage at the seat of 
fracture, by means of free and multiple incisions, combined with 
general supportive treatment. Amputation is not an unusual neces- 
sity, when this active surgical management is omitted or delayed. 

Shock and Hemorrhage. — These two conditions are occasionally 
found complicating severe fractures. They are seen most frequently 
in fractures of the skull, ribs, pelvis, and femur. The two conditions 
are very often characterized by similar symptoms, but they should 
be differentiated. Shock is seen most frequently in multiple fract- 
ures accompanied by considerable bruising of the soft parts, and in 
patients who have been transported for a considerable distance. 
Hemorrhage is seen especially in fractures near large vessels and in 
those which communicate with visceral cavities, into which extensive 
hemorrhage may occur without external evidence. 

Treatment of shock should consist in absolute immobilization of 
the fragments, general stimulation, the application of external heat, 
and the use of remedies applicable to shock from other injuries. 

In cases of suspected, concealed, or internal hemorrhage it may 
be necessary to expose the seat of fracture and ligate the bleeding 
vessel, especially if the hemorrhage is extensive and endangering the 
life of the patient. 

Traumatic Delirium. — This is a condition occasionally seen as 
a complication of fractures in the young and those who are not 
addicted to the use of alcohol. The condition occurs generally in 
person^ who have been under considerable mental stress for years, and 
is similar in character to post-operative delirium. The chief symp- 



GENERAL CONSIDERATIONS 37 

toms of the condition are low, muttering delirium without fever. 
The patient's attention can at times be fixed, only to be quickly lost; 
the events of the past are recalled, and the subject causing mental 
anxiety is uppermost in the patient's mind. Refusal to take food, 
relaxation of the sphincters, and rapid emaciation are also symptoms 
occasionally seen. 

The treatment of the condition is forced feeding, watching the 
excretions, care of the dependent parts of the body so as to prevent 
bed-sores, and the use of a general tonic. The prognosis in this form 
of delirium is usually good, but at times death follows. It is not as 
dangerous a complication in fractures as is alcoholic delirium. 

Alcoholic Delirium. — The onset of delirium in patients sub- 
ject to the use of alcohol is a very common and at the same time a 
grave occurrence. As a complication of fractures it is a condition 
always to be dreaded. Its symptoms consist of muscular twitchings, 
delirium from which the patient may be aroused at first, an increase 
in pulse rate, a flushed face, hallucinations, restlessness, insomnia and, 
finally, delirium with unconsciousness. These patients are difficult to 
restrain. They are liable to insist upon removing dressings and all 
forms of apparatus, and unless carefully watched will walk around 
with portions of their fracture dressings hanging from them. Even 
with fracture of the femur or of the bones of the leg, patients will get 
out of bed and attempt to walk unless restrained. Attempts at 
violence and self-destruction are comparatively frequent. 

The onset of the delirium may be sudden or gradual. If there has 
been loss of blood or shock, the onset, as a rule, is sudden. In other 
cases its onset begins about two to four days after the injury and 
patients pass rapidly from the earliest symptoms to complete insomnia, 
and show violence. Very often in addition there occurs either sepsis 
or pneumonia. Death often rapidly follows. 

Treatment consists in early recognition of the condition, in the 
use of alcoholic stimulation, chloral by mouth or rectum, forced feed- 
ing, particularly of liquids, and restraint. Great care must be taken 
that these patients do not injure themselves or others, and that they 
are frequently moved in bed to prevent hypostatic pneumonia. The 
back and all dependent portions of the bod}' should receive most 
careful attention to obviate bed-sores, which may occur despite the 
patient's restlessness. 

Pulmonary Complications. — The occurrence of pneumonia as 
a complication is not frequently seen, but it may develop during the 
first few days. Its cause is not known, but the occurrence of fat 
emboli may have something to do with its onset. As a rule it is not 
preceded by a chill; the course of the disease is rapid. It is generally 
lobar in type, is accompanied by high fever and muttering delirium, 
and a fatal result may occur within a few days. 



38 TREATISE ON FRACTURES 

Another form of lung complication is perhaps more frequent than 
the lobar pneumonia above described. It is a bilateral hypostatic in- 
volvement of the posterior aspect of the lungs, and is seen most 
frequently in those of advanced life. Its onset is gradual, there is no 
chill, and only moderate fever. The course of the disease is slow 
and fatal in many cases. The condition is favored by long recum- 
bency in one position. Pathologically, it consists of extensive venous 
congestion of the lower lobes, and it is a very frequent sign of failure 
of the heart and general decline in the body functions. 

The treatment consists in turning the patient frequently or other- 
wise changing his position, massage, and general stimulation. The 
prognosis of this condition is very bad. 

Bronchitis is another pulmonary complication of fractures. It is 
seen most frequently in the aged, as a coincident disease with various 
forms of delirium, and may be caused by failing cardiac power or as 
the result of inspiration of particles of food. It is generally a diffuse 
condition, more pronounced posteriorly than anteriorly, and is pro- 
gressive in character, generally ending in a lobular pneumonia which 
is fatal in a short time. Its treatment is purely symptomatic. 

Cardiovascular Changes. — These consist in alterations in the 
heart muscle, which undergoes a fatty degeneration, and changes in 
the coronary vessels. There may be no evidence of myocardial or 
coronary change while the patient is in bed. It only becomes evident 
after the patient is out of bed and is characterized by precordial dis- 
tress, dyspnoea, cyanosis, and later by failing compensation and oc- 
casionally by sudden death. Most of these cases are incorrectly 
classified as due to pulmonary emboli. Post-mortem examination 
reveals no evidence of pulmonary emlx)li. but the heart shows an 
increase of fat in the epicardium. The heart muscle is yellowish 
brown, friable and soft, and the coronary arteries are atheromatous. 

The treatment in those cases which are not rapidly fatal is rest, 
mental and physical, and later moderate exercise and bath. 

Epiphyseal Separations 
Anatomy. — All bones are formed in the embryo either in mem- 
brane, or in cartilage covered by membrane. Ossification takes place 
beneath this membrane in all and exclusively in some, as the clavicle. 
The diaphysis or bod}- of the bone has one or more primary centres 
of ossification. The- epiphysis has one or several secondary or tertiary 
centres of ossification, which are united to the diaphyses for a time by 
epiphyseal cartilage. The epiphyses or secondary centres help to form 
the extremities of the long bones or the projecting processes. An 
apophysis is a prominent projection of bone which is not developed 
from an independent centre of ossification. The primary centres 



GENERAL CONSIDERATIONS 39 

appear in the diaphyses of long bones before birth, with several ex- 
ceptions. The secondary centres in the epiphyses appear after birth, 
with the exception of the upper epiphysis of the tibia, the lower 
epiphysis of the femur, and the upper epiphysis of the humerus. The 
diaphysis is separated from the epiphyses of the long bones by an 
intervening layer of cartilage called the epiphyseal cartilage. Growth 
occurs from the centres in the diaphysis and epiphyses, accompanied 
by a corresponding growth of the epiphyseal cartilage. When the 
bone has attained its full growth, union of the diaphysis and epiphyses 
takes place by ossification of the epiphyseal cartilage. Bones increase 
in diameter through deposit of bone from the periosteum. The follow- 
ing rules of bony union of the diaphysis and epiphyses have been laid 
down by Gerrish : 

" I. The extremity whose ossific centre is the first to appear is the 
last to unite with the shaft. Exception : the lower end of the fibula, 
but the upper end is vestigial. 

" 2. The extremity toward which runs the nutrient artery is the 
first to unite. 

"3. The nutrient arteries run toward the elbow and away from 
the knee, i.e., down hill, if elbow and knee are both flexed. 

" 4. Union of the epiphyses and diaphyses of long bones occurs 
from the sixteenth to the twenty-second year (occasionally twenty- 
fifth year, tibia) and earlier in the upper than in the lower extremity. 

"5. AYhen two or more centres of ossification occur in an epiphy- 
sis, these unite together before the epiphysis unites with the diaphysis 
or shaft." 

The Date of Ossification of the Epiphyses and the Time 
of Union of the Epiphyses to the Diaphyses. — The inferior 
maxilla is formed in membrane about Meckel's cartilage. There are 
four to six centres of ossification. From the symphysis to the mental 
foramen ossification takes place in Meckel's cartilage; the condyles 
and angles ossify from separate centres in cartilage. The rest of the 
bone develops in membrane. At birth the two halves of the mandible 
are separated by a synchondrosis, and they do not unite until after the 
first year. 

Hyoid Bone. — Is preformed in cartilage ; there is a centre for each 
cornu and for each half of the body. Ossification of the body and 
greater cornu begins at birth, of the lesser cornu at a later period. 
Ossification of the synchondrosis of the body and greater cornu occurs 
usually after middle life. The synchondrosis of the lesser cornu 
seldom ankyloses. 

The scapula is preformed in cartilage during fetal life; ossifica- 
tion occurs from two primary and five secondary centres. The primary 
centres are on the body and coracoid processes, which unite about the 



40 TREATISE OX FRACTURES 

fifteenth vear. Two centres appear in the acromion at the fifteenth 
year, unite and join the spine at the twentieth year. 

The clavicle is preformed in cartilage (prechondral tissue), and 
the main centre of ossification appears about the seventh week of 
embryonal life. It is the first bone to ossify. An epiphyseal centre 
appears at the sternal end about the fifteenth to eighteenth years and 
unites with the shaft about the twentieth year. 

The sternum is preformed in cartilage; the manubrium is gener- 
ally developed from a single centre, the gladiolus from four to twelve 
centres and the xiphoid from one centre. Ossification of the sternum 
begins about the fourth to sixth month of fetal life, and the xiphoid 




I 

Fie. 21.— Epiphyseal lines of upper cad of right humerus, acromial process of scapula. 

from the sixth to the twentieth year. Failure of union of the two 
halves of the sternum results in a median foramen or vertical fissure. 

The ribs are preformed in cartilage and have a primary centre near 
the angle. Epiphyseal centres appear for the heads and tubercles after 
puberty, and unite with the main portions of the hone about the 
twenty-fifth year. 

Vertebra. — Each vertebra has three centres of ossification, one 
for the body, and one for each half of the vertebral arch. Ossification 
begins at the end of the second month of embryonal life. Accessory 
centres appear about the age of puberty, at the spinous and tran>ver^- 
processes, on the mammillary processes of the lumbar vertebral, and 
on the upper and lower surfaces of the vertebral bodies. These 



GENERAL CONSIDERATIONS 41 

accessory epiphyses unite with the remainder of the vertebra when 
growth has been completed. 

The humerus (Figs. 21 and 22) is developed from a centre of 
ossification for the diaphysis, which appears during the eighth week 
of fetal life, and six or seven secondary centres for the extremities 
which appear after birth, the epiphyses being cartilaginous. During 
the first year the centres appear in the following order : upper epi- 
physis for the head, the capitellum, the greater tuberosity, the lesser 
tuberosity, the trochlea, the external and internal epicondyles, which 





Fig. 22. — Epiphyseal lines and centre of lower end of humerus, and upper ends of radius and ulna. 

appear between the tenth and twelfth years. Complete ossification 
and disappearance of the synchondroses from the twentieth to the 
twenty-second year. 

Radius (Figs. 22 and 23). — The centre for the diaphysis appears 
in cartilage about the third fetal month, the secondary centre for the 
head appears about the fifth year and unites to the shaft about the 
fifteenth year; and a secondary centre for the lower end appears 
shortly before the upper one, but does not unite with the shaft until 
the twentieth year. Accessory nuclei appear for the tubercle and 
styloid process. 



42 TREATISE OX FRACTURES 

Ulna (,Figs. 22 and 23). — The centre for the shaft occurs in 
cartilage about the third fetal month: the upper end of the olecranon 
is ossified from a secondary centre for the olecranon and another for 
the coronoid process, which join the shaft about the sixteenth year. 
There is also a secondary centre for the lower epiphysis which forms 
the styloid process and joins the shaft from the eighteenth to the 
twentieth year. 

Carpal Rones ( Fig. 23). — All the carpal bones ossify from a 
single centre and are cartilaginous at birth. The centres for the 
os magnum and unciform appear during the first year; and for the 
other bones between the third to the ninth year, with the exception 
of the pisiform, which does not begin to ossify till the twelfth year. 

The metacarpal bones (Fig. 23) are preformed in cartilage and 
ossify from a diaphyseal centre for the shafts and an epiphyseal 




Fig. 23. — Epiphys 

centre in the head, except the so-called metacarpal bone of the thumb, 
which has its epiphyseal centre in the base. The diaphyseal centres 
appear in the ninth week of fcetal life and the epiphyseal centres appear 
after birth. 

Phalanges ( Fig. 23). — They are pre formed in cartilage and their 
centres form in a similar manner to those of the first metacarpal; a 
diaphyseal centre, and an epiphyseal centre in the proximal end. The 
proximal phalanx ossitic> first, then the middle one, and finally the 
distal one. 

The innominate bone ( Figs. 24 and 25 ) is preformed in cartilage, 
there being three main centres of ossification, one for the ilium, one 
for the ischium, and one for the pubes; the centres appearing at the 
third, fourth and fifth months of fetal life respectively. At birth a 
large part of the innominate lx>ne is cartilaginous and remains so for 
some time. The three portion- join by the ossification of the Y-shaped 



GENERAL CONSIDERATIONS 



43 



cartilage, where they meet in the acetabulum, about the sixteenth to 
the twentieth year. There are, in addition, secondary centres of 
ossification as follows : one each for the crest of the ilium, the tuber- 
osity of the ischium, the spine of the ischium, the symphysis pubis, 
the anterior inferior spine of the ilium, the spine of the pubis, and 




Fig. 24. — Epiphyseal lines of part of pelvis and upper end of femur. 

two for the acetabulum. These epiphyses unite with the main portion 
of the bone about the twenty-fifth year. 

Femur (Figs. 24 and 26). — This bone develops from a diaphyseal 
centre and two primary epiphyseal centres. The diaphyseal centre 
appears about the seventh week of embryonic life and the lower 
epiphyseal centre is generally visible at birth ; the centre for the head 



11 



TREATISE ON FRACTURES 



appears about the end of the first year, that for the great trochanter 
about the fourth year, and that for the lesser trochanter about the 
fourteenth year. The epiphyses unite with the shaft in the following 
order and time: lesser trochanter, seventeenth year; great trochanter, 




-Epiphysea 



eighteenth year; head, nineteenth year; condyles, twentieth to twenty- 
first year. The neck is an outgrowth from the shaft. 

Patella | Fig. 26). — The patella is formed from a single centre of 
ossification, which appears about the fourth year, and ossification is 
complete about the fifteenth year. 

Tibia (Figs. 26 and _>;). — The centre for the diaphysis appears 
about the seventh week of fetal life; the centre for the upper epiphysis 



GENERAL CONSIDERATIONS 



45 



which includes the tubercle ossifies about the time of birth, and the 
centre of the lower epiphysis ossifies about the beginning of the 
second year. The lower epiphysis unites with the shaft about the 
eighteenth year and the upper epiphysis about the twenty-second year. 
Fibula (Figs. 26 and 27). — The centre for the diaphysis appears 
about the eighth week of embryonic life; the centre for the lower 
epiphysis appears about the second and that for the upper epiphysis 
about the third or fourth year. The lower epiphysis unites with the 
shaft about the twentieth year and the upper one from the twenty- 
second to the twenty-fourth year. 



Fig. 26. — Epiphyseal lines and centres of lower end of femur, patella, and ends of tibia and fibula. 

Tarsal Bones (Fig. 27). — The centre for the calcaneum appears 
about the sixth month and that for the astragalus in about the seventh 
month of embryonal life ; the centre for the cuboid appears at birth ; 
the external cuneiform ossifies about the first year, the internal cunei- 
form the second year, and the middle cuneiform and the scaphoid 
from the fourth to the fifth year. The calcaneum is the only tarsal 
having an epiphyseal centre of ossification which appears about the 
tenth year and unites with the remaining part of the bone at about 
the fifteenth or the sixteenth year. 

Metatarsal Bones (Fig. 28). — The centres of the diaphyses ap- 
pear about the eighth to ninth week of fetal life and the epiphyseal 
centres in the third to the fourth year and unite with the diaphyses 
about puberty. The ossification is similar to that which takes place 
in the metacarpal bones. 

Phalangeal Bones (Fig. 28). — Here the process of ossification is 
similar to that seen in the phalanges of the hand. The centres of the 



HI 



TREATISE ON FRACTURES 



diaphyses appear in about the third month of fetal life, the epiphyseal 
centres in about the fourth year, and union of the diaphyses and 
epiphyses takes place about the time of puberty. 

Etiology of Epiphyseal Separation. — Epiphyseal separations may 
be due to violence, direct or indirect, or to muscular action. 

Direct Violence. — This is a frequent cause of epiphyseal separa- 
tions which are produced by force applied close to the epiphyseal line. 
Examples are: fall from a moderate height with striking of the 




Pig. 27. — Epiphyseal lines and centres of lower end of tibia and fibula, and o 

shoulder, catching an extremity in a revolving wheel, or having a 
wheel pass over the part, and having the part struck by a heavy object. 
Indirect Violence.— Epiphyseal separations are produced by in- 
direct violence by falls upon the hand, producing separations at the 
epiphyses in the young where fractures would he produced at the same 
site in the adult. Examples of separations are: those at the wrist 
simulating Colles's fracture, separations at the elbow by falling upon 
the hand or by hyperflexion or extension, or catching the limb in a 
revolving wheel. 



GENERAL CONSIDERATIONS 47 

Muscular Action. — This is a very rare etiologic factor in epi- 
physeal separations. It is occasionally seen in severe muscular action, 
by which an epiphysis may be displaced owing to the attachments of 
strong muscles or ligaments. The same amount of strain in an adult 
would probably produce a sprain fracture or the separation of an 
apophysis. A good example of this is separations of the internal 
epicondyle. 

On general principles, it may be stated that the mechanism of most 
separations is the same that produces* fractures near joints in adults. 

Occurrence of Epiphyseal Separations. — Ossification of all the 
epiphyseal cartilages has usually occurred before the twenty-fifth 
year, hence epiphyseal separations can rarely happen at a later period 
of life. Poland has shown that epiphyseal separations are rare before 
the as:e of four years, excepting, of course, those produced in obstetric 




Fig. 28. — Epiphyseal lines and centres of metatarsal and phalyngeal bones of foot. 



delivery, but are most frequently found between eleven or twelve and 
sixteen years. 

Dependent upon the age of the patient there may be several forms 
of separation of the epiphyses. In early childhood the separation does 
not involve the diaphysis to any appreciable extent. After the age 
of eight or nine, nearly all epiphyseal separations are accompanied 
by a fracture of the diaphysis, which may be vertical or oblique, or 
consist of only a very small part of the cortex of the diaphysis. With 
the increase of age occurs a greater tendency for marked stripping off 
of the periosteum. In early childhood this is not marked, but in later 
childhood it may extend four to five inches along the shaft of the 
bone. The extent of this stripping is dependent upon the degree of 
displacement of the epiphysis and the epiphysis involved. It is 
greatest in separations of the lower epiphysis of the femur and of 
the upper epiphysis of the humerus. 



48 TREATISE ON FRACTURES 

A point to be borne in mind in separations of the epiphysis is that 
fracture of the epiphysis itself may be associated with the separation. 
This is most commonly met in separations of the lower epiphysis of 
tbe radius and in those of the metacarpals and phalanges. 

Separation of the epiphysis may involve single epiphyseal centres, 
or combined epiphyseal centres; the latter condition being seen when 
childhood is advanced and the several centres forming an epiphysis 
have fused. 

Epiphyseal separations may be complete or incomplete. Complete 
epiphyseal separations are so classified when the separated epiphysis 
is entirely displaced from its diaphyseal position. Complete separa- 
tions are produced by great violence, or because obliquity of the line 
of tbe epiphyseal cartilage is associated with moderate violence. In- 
complete separations are the most common form seen. They are fre- 
quently mistaken for sprains, and even with radiographic examination 
may be overlooked. In most cases, however, a careful examination 
of tbe radiographic plate will disclose a little irregularity of the sur- 
face lines of the bone or a slight fracture of the epiphyseal end of 
tbe diaphysis. At times it is impossible to distinguish clinically be- 
tween epiphyseal separation and a fracture of the diaphysis. A radio- 
graphic examination should be made in all suspected cases. 

Symptoms. — Age. — Injuries about joints in childhood should im- 
mediately suggest the possibility of an epiphyseal separation. The 
presence of marked swelling should point to some grave injury near 
the joint. 

Mobility. — This is dependent upon whether the separation is com- 
plete, incomplete, or impacted. When the separation is not impacted 
there is usually slight mobility in incomplete separations and marked 
mobility of the epiphysis in complete separations. The mobility is 
dependent upon the extent of laceration of the ligaments and peri- 
osteum. 

Deformity. — This may consist in swelling about the joint alone. 
There may be no deformity in incomplete and in reduced separations. 
In complete separations the metaphyseal end of the epiphysis may be 
felt as an irregular, smooth projection, and the size and shape of the 
involved epiphysis may be outlined. It is well to remember, however, 
that in many cases of epiphyseal separation there may be an attached 
fragment of the diaphysis, which will alter the normal shape of the 
epiphyseal fragment. The axis of the part may be displaced, as in 
fracture. 

CREPITUS. — This differs from the crepitus found in true fractures. 
When it can be elicited, it is soft in character, and may be produced 
only by rather vigorous manipulation. In impacted separations it is 
absent; in separations in which there is a fairly large sized piece of 
the diaphysis attached, it may be more bony in character. 



GENERAL CONSIDERATIONS 49 

Pain. — This is not as great as in fractures. There is, however, 
generally localized tenderness on pressure over the epiphyseal line; 
this symptom, combined with localized swelling, is of great diagnostic 
value in recognizing epiphyseal separations. 

Ecchymosis is not as marked as in fractures. This is probably 
due to the fact that the vascular system involved consists of terminal 
vessels. When present it becomes evident about the fourth to fifth day. 

Radiographic Examinations. — These are of especial value and 
should always be made in suspected cases. Skiagraphs should be made 
in several planes, as it may be that positive diagnosis is possible only 
by comparison of the outline of the affected bone with that of the 
normal side. The surgeon should particularly familiarize himself 
with the normal X-ray appearances of the epiphyses at all ages, if 
correct interpretation of these radiographic plates is to be made. 
Examination of the plates by transmitted light is much more satis- 
factory than inspection of prints. More care is required than in 
fractures. Very often the only abnormality to be seen will be a slight 
difference in outline or a loss of normal continuity of the epiphysis 
with the diaphysis. In other cases one may discover a fissure or a 
partial fracture of the metaphyseal end of the diaphysis, with dis- 
placement of the fragment along with the epiphysis ; in still other 
cases there may be noted a stripping off of periosteum. Radiographic 
pictures of the normal corresponding part should be taken for com- 
parison with the injured side. 

Diagnosis. — This is made from a consideration of the patient's 
age, the nature and position of the injury, the site of tenderness and 
swelling, the characteristic displacement if any be present, the absence 
of normal bony crepitus, the presence of mobility in the region of the 
epiphyseal line, and, lastly, by radiographic examination. The last is 
of utmost importance in the recognition of these lesions. 

Complications of Epiphyseal Separations. — These are injuries 
to blood-vessels, and lesions from nerves being caught between 
the diaphysis and the epiphysis, fracture of the diaphysis, rotation and 
displacement of the epiphysis, necessitating operative exposure for 
proper replacement, and the occasional occurrence of an open epi- 
physeal separation. 

Sequelae of Epiphyseal Separations. — Perfect reduction of epi- 
physeal separations should give perfect anatomical and functional 
results. It is surprising how rarely there is any interference with the 
subsequent growth of the bone after epiphyseal separations. While 
there are cases of subsequent interference with the growth of the 
bone (Fig. 29), this sequel seems to be rare in comparison with the 
great number of epiphyseal separations observed in childhood. 

Treatment. — In all cases of complete or incomplete separation 
4 



)0 



TREATISE ON FRACTURES 



of the epiphysis, attempts at reduction should be made. An anaes- 
thetic will be required in many instances. Very often stripped off 
periosteum or rotation of the epiphysis will prevent accurate anatom- 
ical reduction. Then deformity is found to be persistent and prob- 
able interference with growth will occur. In these cases, if proper 
reduction cannot be accomplished, the site of the epiphyseal separa- 
tion should he exposed under the most thorough aseptic precautions 
and reductions secured. The reposition may be maintained by a few 




Fi... 29. -Shows interference with subsequent growth of the fourth metacarpal following a previous 
epiphyseal separation. 

absorbable sutures, uniting torn ligaments, periosteum, or surrounding 
muscles, While some authorities advise direct suture of the epiphysis 
to the diaphysis, we are not in accord with this teaching as a routine, 
and believe that as good results can be accomplished by the means 
outlined above without running the chance of possibly interfering 
with subsequent growth of the hone. In all cases after reduction, the 
form of external support should be similar to that used for fracture 
of the diaphysis near the end of the hone involved. Open epiphyseal 
separation^ should be treated like open fractures near joints. 



GENERAL CONSIDERATIONS 51 

Prognosis. — The prognosis after fractures is dependent upon 
many factors. It is a common mistake to imagine that perfect function 
will be present as soon as union is firm. The prognosis will depend 
upon the age of the patient, the variety, nature, and site of the injury, 
the character of the violence, the presence of changes in alignment and 
weight bearing, the future stress on joints due to poor anatomical 
apposition of the fragments, and to the occurrence of complications. 
The prognosis is greatly modified by the surgeon's neglect or care of 
the soft parts in the vicinity of the fracture. Frictions, light massage, 
and early attention to the joints and muscles are often as important 
as reduction of the fragments and their fixation. 

Fractures unite more rapidly in children than in adults. The 
deformities in bony outlines following fractures in children generally 
tend to grow less and the functional results improve as the patient 
grows older. F. Konig and also Birt have shown this conclusively. 
While this is true in many cases, it is also true that many deformities 
are not only disfiguring, but many increase and ultimately interfere 
with the function of joints 'and extremities. A good example of this 
is traumatic coxa vara occurring in the neck of the femur of the 
young. The deformities due to improper reduction, while they are 
not as difficult to correct in children as in adtdts, are very trouble- 
some; and surgeons should endeavor to obtain perfect approximation 
of the fragments at the time of the injury. 

Beyond middle life the prognosis of fractures is less favorable, 
and in advanced life it is generally very poor. This is due to several 
factors. The principal ones are the rarefying process which takes 
place in bones in advanced life, the difficulty of giving proper care 
to these patients, and an increased liability of traumatic delirium, 
alcoholic delirium, hypostatic pneumonia, and cardiac degeneration. 
In these instances much depends upon the good judgment of the 
surgeon as to the proper local treatment of the lesions in bone and 
soft parts. Routine methods may work harm. 

Fractures which are closed and uncomplicated are usually fol- 
lowed by good functional results if the treatment is mechanically and 
physiologically wise. Open fractures are more liable to infection, 
necrosis, shortening, and deformity. Fractures which are oblique or 
spiral are usually more difficult to retain in proper position and are 
therefore followed more frequently by shortening, or rotary or angular 
deformity. Fractures in which the line of fracture is transverse gen- 
erally remain in proper position when carefully reduced, and if proper 
reduction is maintained the anatomical and functional results are 
good. Fractures involving joints or in close proximity to joints aie 
not infrequently followed by partial limitation of the normal motions 
of the joint. Examples of this are fractures about the elbow and 



52 TREATISE ON FRACTURES 

ankle- joints, in which there remains in a considerable number of case9 
a certain degree of limitation. Fractures of one of the parallel long 
bones are generally followed by a good result, because the other bone 
acts as a splint and preserves the longitudinal alignment. This, how- 
ever, is not ahvavs the case, as is seen in spiral and oblique fractures 
of the tibia. Fractures of the spongy bones are usually followed by a 
certain amount of deformity, owing to the crushing and comminution 
of tlie fragments. Fractures of the small bones unite sooner than 
fractures of the large bones. Fractures will sometimes be followed 
by imperfect anatomical and functional results, notwithstanding all 
efforts at perfect reduction and approximation and expert supervision. 

Changes in the soft parts and of the neighboring joints may 
influence the prognosis. Stiffness of the articulations, adhesions about 
joints, oedema and congestion of the parts which are increased when 
the dependent position is assumed, and pain aggravated by changes 
in the weather are some of the common sequeke of fractures. These 
changes may require months for their disappearance, and in many 
cases are permanent. It is practically certain that to a considerable 
degree stiffness of joints, adhesions of tendons, cedema, and pain may 
1>e averted if, in addition to reduction and mechanical support, fract- 
ures are treated with frictions and light massage, and passive motions. 
While we may have perfect anatomical apposition of the fragments, 
the presence of these changes in the soft parts about the fracture may 
greatly lessen the good functional results which should be otherwise 
obtainable. Stiffening of neighboring joints is generally due to the 
simultaneous involvement of the joint structures in a sprain, to the 
hemorrhagic extravasation around or into the synovial sac, to the 
involvement of tendons in ossifying callus, to the contraction of peri- 
articular ti>sue and ligaments during the time of immobilization, and 
to the development of excessive callus about the joint surfaces. This 
stiffness i> most marked and most persistent in the aged and in those 
subject to rheumatoid arthritis. CEdema is the result of pressure 
upon deep veins by fragments of bone or callus or the development 
of a phlebitis resulting from the deposit of fibrin about the seat of 
tract ure. Protracted immobilization of fractures in splints, infre- 
quent examination and neglect of the care of the skin and muscles 
during the wearing of the splints are undoubtedly responsible for 
many of these sequelae. Attention to the soft parts in the manner 
advocated by Lucas-Championniere and his followers will obviate 
many of these difficulties. 

General Statistics 

I lure are so many elements entering into the prognosis of fracture 
that it i> difficult to give any general statistics that will cover all forms. 
Each case must be considered on individual grounds, and each class of 
fractures occurring in the same bone must be grouped. Statistics even 



GENERAL CONSIDERATIONS 53 

then are at times of little use in forming an opinion of an individual 
fracture. 

General statistics and statistics of individual fractures of the long 
bones were published in November, 19 12, by a Committee of the 
British Medical Association appointed to report on the ultimate results 
obtained in the treatment of simple fractures with or without opera- 
tion. The Committee limited its inquiry to closed fractures of the 
long bones which occured or in which operations had been performed 
in the period January 1906, to December, 19 10, inclusive. This period 
was selected so that six months should have elapsed since the com- 
mencement of the treatment. During the period mentioned there were 
treated in 15 hospitals 11,946 fractures of the long bones non-oper- 
atively, with a fatal result in 129 cases, a mortality of 1.0 per cent. ; the 
majority of the deaths due either to age, disease or associated in- 
juries. Of the 1040 cases treated by operation, there was a fatal 
result in 8 cases, a mortality rate of 0.77 per cent. Of these 8 cases 
there were 3 cases in which the cause of death was existing organic 
disease, and 2 were directly due to the anaesthetic. The other 3 cases 
were directly attributable to the operation. These were due to sep- 
ticaemia (2 cases) and sepsis (1 case). The ratio of the non-operative 
patients to the operative was about 11^ to 1. The fatalities, there- 
fore, in an equivalent number of patients operated upon would have 
been 11^2 times 5 or S7 Y A- A death rate of 57J/I patients in 11,946 
cases treated by non-blood-shedding methods by men as skilled in the 
methods as were the men doing the operations tabulated, would be 
terrifying. When the total fatalities in the Committee's collection 
of non-operative cases were only 129, including deaths from all causes 
and associated injuries, it is seen that the operative mortality, 5 in 1040 
cases, is too high to meet with approval. 

The Committee examined personally 2948 patients, and with those 
in which there was a fatal result during treatment, a total of 3062 
cases were investigated. No cases of open (compound) fractures 
were studied by the Committee. 

The Committee separated the non-operative cases from the opera- 
tive cases. In the non-operative cases all forms of treatment were 
used. In the operative cases three classes were distinguished : Those 
cases in which operation is decided upon at once and is performed as 
soon as practicable (Class A). Those in which operation is performed 
on account of failure to obtain and maintain accurate apposition by 
means of external mechanical appliances (Class B). Those cases in 
which operation is performed for non-union, for deficient union, or for 
faulty union whether in progress or complete (Class C) . 

An analysis of all results, non-operative and operative, clearly 
showed the interdependence of the anatomical and functional result. 
The total number of cases in which a good anatomical result was 



54 



TREATISE ON FRACTURES 



obtained was 1736, and in no less than 1576 of these the functional re- 
sult was also good. In other words : " If the anatomical result be good 
the functional result is good in 90.7 per cent. If the anatomical result 
be moderate or bad, the functional result is good in 380 out of 1279 — 
i.e., 29.7 per cent. If the anatomical result be bad, the functional is 
bad in 176 out of 330 — i.e., 53.3 per cent." 

The comparison of the result obtained by non-operative and oper- 
ative treatment was as follows: 

Comparison of the Results of Non-operative and Operative Treatment 



I. Non-Operative 



No. of Cases 

Good Anat \ 

Good Funct ) 

Bad Anat \ 

Bad Funct j 

.Moderate or Bad 

Anat 

Good Funct 

Good Anat 1 



Mod. 
Funct. 



Bi 



2596 

1422 = 54.3 percent. 

169= 6.5 per cent. 
419=16.1 percent. 

138 = 5-3 percent. 



I. (Class A) II. (Class B) III. (Class C) 



147 

108 = 73.4% 

5= 3-4% 

9= 6.1% 

9= 6.1% 



78 

32 = 41-0% 
8=10.2% 

15=19-2% 
6= 7-6% 



83 

15 = 18.0% 

28 = 33-7% 

17 = 20.4% 

7= 8.4% 



The figures in the second and fourth lines added together give the 
number of cases in which a good functional result was obtained. 

A just criticism of this report is that no distinction was made 
between the types of non-operative treatment or of the varying ability 
of the practitioner ; while in the operative class at the date of investiga- 
tion most of the operations were done by expert surgeons, and the 
operative cases were divided into three classes. 

An attempt was made by the Committee to determine the influence 
of age upon the result of treatment. They found that for all practical 
purposes age groups might be condensed into children (0-15), and 
adult life (over 15). Of the non-operative cases there were 1016 
under 15 years, with a good functional result in 90.8 per cent., and 
[580 over 15 years, with a good functional result in 45.4 per cent. 
( )f the operative ( Class A ), there were 64 cases under 15 years, with 
good functional result in 93.6 per cent., and 83 cases over 15 years, 
witli good functional result in 66.3 per cent. 

The Committee determined that the percentage of good functional 
results (disregarding entirely the anatomical results) is smaller with 
each succeeding age group. Their analysis shows that under each 
age group there is a progressive depreciation of the functional result 
ol" the non-operative treatment as age advances; in other words, the 
older the patient the worse the result. 

Attempts to determine the periods of incapacitation of the non- 
operative were more successful than of the operative cases, owing to 



GENERAL CONSIDERATIONS 55 

the small number of the latter studied. Of the non-operative cases 
under fifteen years, the number of cases in which the period of in- 
capacitation was stated was 590, the average number of weeks of 
incapacitation was 14.7, and the number of cases in which incapacita- 
tion was permanent was 1. Of the non-operative cases over 15 years, 
the number of cases in which the period of incapacitation was stated 
was 1324, the average number of weeks of incapacitation was 27.6, 
and the number of cases in which incapacitation was permanent was 
121, or 9.0 per cent. Of the operative cases (Class A) under 15 
years, the number of cases in which the period of incapacitation was 
stated was 13, the average number of weeks of incapacitation was 
12.2, and there were no cases of permanent disability. Of the opera- 
tive cases (Class A) over 15 years, the number of cases in which the 
period of incapacitation was stated was 64, the average number of 
weeks of incapacitation was 27.3, and the number of cases in which 
incapacitation was permanent was 5, or 7.8 per cent. Of the operative 
cases (Class C) the number of cases in which the period of incapacita- 
tion was stated was 51, the average number of weeks of incapacitation 
was 76.6, and the number of cases in which incapacitation was perma- 
nent was 8, or 15.6 per cent. Of all fractures over 15 years, non- 
operative and operative (Class C), the number of cases was 1375, the 
average duration of incapacitation was 29.3 weeks and the number of 
cases in which incapacitation was permanent was 129 or 1.0 per cent. 

The Fracture Committee of the American Surgical Association, 
appointed in 19 12, has also prepared statistical tables and recorded 
opinions of value. 

In 191 3 it mentioned the opinion of the British Committee that the 
operative treatment required such special skill and experience and such 
facilities to prevent sepsis as made the operative method one not to be 
undertaken except by those in constant practice and experience in sur- 
gical procedures; and referred to its statement that the operative ma- 
terial available for study was so small as to make it undesirable to 
draw final conclusions from its statistics as to the relative value of 
operative and non-operative treatment. 

In 191 5 the American Committee reported further that the present- 
day results in subcutaneous (closed) and air-exposed (open), some- 
times called " compound," fractures, the average time of disability and 
the relative value of non-blood-shedding and blood-shedding methods 
of treatment had been among the points investigated. The British 
Committee had carefully investigated and tabulated 3062 cases in study- 
ing non-operative and operative treatment. The American Committee 
tabulated 1745. Of these there were 1358 non-operative and 387 
operated upon; 258 of the operated cases were subcutaneous (closed) 
fractures, 129 air exposed (open) fractures. 

It found that results are best under 15 years and that treatment 



.36 TREATISE OX FRACTURES 

without operation was generally effective in this period of life. This 
sponded pretty well with the result of the British Committee. 

It also determined that good anatomical restitution of a broken 
long bone results in better functional result than imperfect reconstruc- 
tion and permits a shorter period of disability from ordinary- duty: 
that the final result in air-exposed (open) fractures showed very little 
difference between non-operative and operative treatment so far as 
anatomical result was concerned, but functional result was better after 
operative measures except in such fractures of the shafts of both 
bones, where the reverse seemed to be true. 

The average period of disability. i.e., time lost from work in sub- 
cutaneous fractures was as follows : 

14 ^- 

head and neck of humerus II. 5 

a Ivies of humerus 9.0 

" shaft both bones of forearm 10.8 

- 7.37 months 

g ill sites 4.75 

Dr. W. L. Estes gives the period of disability- in 51 personal patients 
with open fractures as: femur, 13 months: leg, 6 months; upper ex- 
tremity. 4 months. He does not say whether or not these were operated 
upon. 

It seems unfortunate that the British Committee did not attempt to 
separate the non-operative cases into two classes : those in which the 
fixation by splints was a more or less prolonged immobilization, and 
those in which mobilization with light massage similar to the Lucas- 
Championniere method was adopted. One of us (Roberts) is con- 
vinced that the great defect in non-operative treatment for years past 
has been infrequent removal of the external fracture dressings. A con- 
sequent infrequent examination of the position of the fragments and a 
more or less usual neglect of attention to the soft parts by massage and 
mobilization have given rise to bad results. Hence has come the de- 
mand for direct fixation by metal plates introduced through operative 
incisions. It seems possible that American surgeons have been less 
attached to prolonged immobilization than the British surgeons. The 
Continent of Europe has perhaps been more influenced than England 
by the teaching of Lucas-Championniere : that prolonged immobiliza- 
tion alone is a mistake in the non-operative treatment of fractures. 
The Report of May. 19 13. of the Fracture Committee of the American 
Surgical Association, made similar suggc- 

Treatment — General Considerations. — The ideal objective in the 
treatment of all fractures is an anatomical and functional cure — to 

3 possible to 
he patient the best functional result obtainable. The 
be to secure prompt union with as little de- 
formity as i>ossibk\ Unfortunately, at times, a certain amount of de- 



GENERAL CONSIDERATIONS 57 

formity is unavoidable, on account of the situation and the nature of 
the fracture or of the patient's general condition. Usually bony union 
of the fragments is not difficult of accomplishment. Those injuries in 
which there is gross displacement of fragments are readily recognized; 
and their reduction and retention in anatomical apposition ordinarily 
may be readily obtained. In a fair number of instances, however, 
union is obtained with deformity, and interference with subsequent 
function results. The degree of impairment of function and the loss of 
earning capacity of the patient vary, not only with the variety of fract- 
ure but also with the patient's occupation. Impairment of function 
may be very serious in a patient whose occupation depends upon the 
perfect use of the part, while the same condition will have little in- 
fluence in the earning capacity of another. Fractures about joints may 
seriously impair the earning capacity of patients whose livelihood de- 
pends upon the full use of their extremities. Impairment of function 
after fractures of the lower end of the radius may seriously reduce the 
earning capacity of musicians and artists. Bad results after fractures 
of the femur in the neck or above the knee, and especially after fract- 
ure of the tibia near the ankle-joint, seriously impair the earning ca- 
pacity of individuals whose occupation requires marching or prolonged 
standing. Coxa vara, knock-knee, flat foot, chronic arthritis are such 
conditions resulting in impaired function. 

Not only should the radiogram be the guide to diagnosis, when prac- 
ticable, but it should also be the index of treatment and its ultimate 
results. Perfect reduction and maintenance of proper position of frag- 
ments are at times difficult, and mere routine methods of non-operative 
treatment may be found inadequate. A careful study of each fracture 
by the attending surgeon, and proper supervision of treatment often, 
however, will result in better functional results than was anticipated. 
The tendency toward operative treatment of fractures at present much 
in vogue is an indication of the poor results obtained by ordinary 
means in inexperienced or careless hands. If the same degree of atten- 
tion was given to fractures as is given to abdominal surgery, there 
would be better results obtained ; and many obsolete methods used in 
the treatment of fractures, even in large hospitals, would be replaced by 
forms of treatment based upon an intelligent study of each case. It is 
not that there is needed many radical changes in treatment to-day. The 
fault lies in hospital chiefs delegating to assistants, and to house offi- 
cers, the complete charge of fracture patients. If surgeons wish to 
obtain good results, it behooves them to give fractures the very best 
attention. The use of the X-ray has shown their shortcomings, and it 
is only a question of time until the public will demand more efficient 
treatment, better anatomical and functional results, and less incapacita- 
tion from work. 

The treatment of fractures may be considered under the following 
heads : 



58 TREATISE OX FRACTURES 

i. Temporary immobilization of the fragments, transportation of 
the patient. 

2. Reduction of the fragments. 

3. Retention of the fragments : ( I ) without traction : ( 2 ) with 
traction (temporary, permanent): (3) with massage and passive 
motions. 

4. Attention to the soft parts. 

5. Functional treatment. 

6. After-treatment. 

Temporary Immobilization" of the Fragments, Transporta- 
tion of the Patient. — In cases of suspected fracture it is not always 
necessary or wise to make an immediate diagnosis. One's efforts 
should be confined to temporary immobilization of the part, so that the 
patient may be transported to the hospital, home, or physician's office 
for treatment. There are many simple first aid dressings which 
may be applied by the ambulance surgeon or by laymen. Fractures of 
the clavicle and humerus may be temporarily immobilized by the use 
of a suitable sling and fixation to the side: fractures of bones of the 
forearm and hand by an anterior splint of wood with suitable padding 
and bandages and sling: fractures of the jaw by an occipitomental 
figure-of-8 (Barton) bandage; and fractures of the ribs, sternum, or 
costal cartilages by a circular bandage of the chest, or by a swathe of 
muslin or of adhesive plaster. Fractures of the pelvis should be tem- 
porarily immobilized by a tightly applied swathe of muslin or adhesive 
plaster around the hips; those of the femur should be supported by a 
posterior splint from the buttocks to the heel and by an external splint 
from the axilla to the sole. If splints are not obtainable, a temporary 
splint may be made for the thigh bone from broom handles or branches 
of trees and a blanket; or the patient may be transported on a board. 
Fractures of the lower part of the femur and of the bones of the leg 
may be temporarily supported in a pillow and side splints of wood. 
Patients with severe fractures and with fractures of the upper extrem- 
ities when the shock is great, should always be carried. Cases of fract- 
ure of the vertebrae and pelvis should be very carefully transported, in 
order not to increase the injur}- of the spinal cord, or of the internal 
viscera. 

Special beds are convenient in the treatment of fractures requiring 
the recumbent position. The bed should be a narrow one and prefer- 
ably high, so that the attendant may readily lift the patient and easily 
reach each part of his body. A firm hair mattress laid upon slats is 
the best. Any good mattress, without springs, which does not permit 
sagging may be used. The usual hospital bed may be converted into 
a fracture bed by placing slats underneath the mattress from the side 
frame. Special openings in the mattress for using a bedpan are not 



GENERAL CONSIDERATIONS 59 

necessary, if the bedpan and urinal are carefully and intelligently 
placed. It is important in fractures of the femur that the bedpan be 
not a high douche pan, but a receptacle that may be slipped under the 
hips without raising the buttocks much from the surface of the bed. If 
the patient's foot is fastened to traction apparatus, this is especially 
important. For cases of fracture of the vertebrae or pelvis a special air 
mattress is advisable so that pressure sores may be avoided as long as 
possible. 

The sheet under the patient should be kept perfectly smooth 
and should have over it a rubber sheet and a narrow draw sheet ; the 
one for protection to the full size sheet and mattress, the other to per- 
mit frequent changing without greatly disturbing the patient. Dur- 
ing a long confinement to bed, special attention should be paid to the 
shoulder and sacral regions and to the heels, which are subject to pres- 
sure. These parts should be washed twice daily with alcohol containing 
a small amount of alum and dusted plentifully with a smooth powder. 
The greatest possible care should be taken to prevent " bed-sores." 

Reduction of the Fragments. — After the patient has been 
transported to his home, to the hospital, or to the physician's office, a 
thorough examination of the injured part should be made. Great care 
should be observed in the examination of all suspected fractures. The 
clothing should be removed from both the injured and the correspond- 
ing uninjured region, in order to give opportunity for comparison of 
the anatomical landmarks. It is not necessary to cause pain in the 
examination of fractures. The surgeon's diagnosis should be made 
by inspection, by palpation, measurement, and radiography. If the 
clothing cannot be readily taken off, it may be cut and then removed. 
Before reduction is attempted all apparatus for retention should be at 
hand and assistants present to give help. Many fractures of the small 
bones may be reduced without anaesthesia. General anaesthesia, as a 
rule, should be used in the reduction of fractures of the long bones, in 
all fractures where satisfactory reduction cannot be accomplished with- 
out causing needless pain, when muscular spasm must be overcome, 
when fractures are complicated with other conditions, and when the 
radiograph shows failure of anatomical apposition of the fragments 
following previous attempts at reduction. 

Post-mortem examination of a recent case of fracture may show 
cmite an extensive disorganization of muscles, infiltration of the soft 
parts, and extravasated blood. These conditions accompanying the 
injury are to a great extent due to movements of the sharp fragments 
of bone and are not so much the result of the original traumatism it- 
self as to failure of temporary splinting of the part during transporta- 
tion, to improper handling on the part of the patient's friends, or to 
temporary examination by physicians. To prevent such injury the 



60 TREATISE ON FRACTURES 

parts should be protected by an improvised splint, and proper precau- 
tions taken during transportation to insure immobilization. 

The most important object in the treatment of fractures is proper 
reduction. Without complete reduction, proper anatomical apposition 
and correct alignment of the fragments are impossible; and the subse- 
quent treatment may be valueless so far as perfect contour and good 
functional results are concerned. Hence a large proportion of fract- 
ures should be reduced under general anaesthesia. Ether or perhaps 
nitrous oxide gas with oxygen is the preferable agent. Other general 
anaesthetics are, however, used. By anaesthesia the surgeon is able to 
overcome muscular spasm, to thoroughly avoid pain, to calm the appre- 
hension of the patient, and to separate impaction of fragments when 
this is necessary for complete reduction. Moreover, interposition of 
soft parts may be more readily removed by manipulation, and disloca- 
tions accompanying fractures reduced. Above all else, perfect replace- 
ment of the fragments is much more likely to be obtained under general 
anaesthesia, while only partial reduction may be unwittingly accepted 
without anaesthesia. Lerda and Quenu have used cocaine or novocaine 
to diminish muscular spasm and pain. They inject a solution of the 
drug into the muscles and tendons about the fracture and if possible 
about the regional nerve. They also force it into a joint capsule, and 
into tendons and ligaments above the joint. This method to overcome 
muscular spasm and pain may be useful for patients where old age, 
defective cardiac or renal function, shock, etc., contraindicate general 
anesthesia. 

Time of Reduction. — As a general rule, reduction of the fragments 
should be performed as soon as shock has been overcome and proper 
facilities are at hand for retention of the fragments. In some cases 
immediate reduction is imperative and should be performed at once. 
These are injuries in which the fragments press upon or are lacerat- 
ing important vessels or nerves, or in which sharp fragments are about 
to perforate the skin or penetrate important vessels, nerves, or viscera. 

Obstacles to Reduction. — Reduction may be prevented by inter- 
position of soft parts between fragments, rotation of small pieces of 
bone, piercing of muscles, tendons, and fascial by the sharp ends of 
fragments, the presence of an accompanying dislocation, impaction of 
fragments, extreme subfascial swelling, and muscular spasm. Asso- 
ciated injuries or complicating conditions, such as profound shock, 
hemorrhage, or approaching death may render immediate attempts at 
replacement unwise. When it is impracticable for any reason to imme- 
diately reduce the fragments, the reconstruction, as a rule, should not 
be delayed more than about a week. In the meantime efficient immobi- 
lization of the fragments, combined with extension if necessary, should 
be maintained. 



GENERAL CONSIDERATIONS 61 

The actual reduction of a fracture varies with the situation and 
variety of the lesion. No one method is applicable to all fractures. In 
fractures of the long bones reduction, as a rule, is accomplished by trac- 
tion, counter-traction, manipulation and lateral moulding. The sur- 
geon estimates by palpation, measurement, and comparison with the 
opposite side, the extent of displacement needing correction, and simi- 
larly determines the degree of reduction, alignment, and anatomical 
apposition which has been accomplished. As a rule, he attempts to 
reduce the fragments by flexion of joints to overcome muscular spasm 
and then tries to bring the lower fragment or fragments into proper 
relation with the upper by rotation, abduction, adduction, flexion and 
extension, combined with traction. Fractures, in which it is recognized 
that the proximal fragment assumes a certain position from the pull of 
attached muscles, are reduced by bringing the distal fragment into ap- 
propriate position. Impacted fractures may be reducible only by con- 
siderable force, which must be applied so as to break up the impaction 
before the readjustment is possible. Powerful bending may be re- 
quired to unlock the impaction. Fractures accompanied by over-riding 
or lateral displacement, in which the line of fracture is serrated and 
transverse, may generally be reduced by traction alone. Often direct 
pressure and lateral traction combined with extension may be neces- 
sary to produce reduction of fragments. Rotary displacement may be 
corrected by proper rotation of the lower fragment. Subperiosteal, 
green-stick and impacted fractures are often corrected by forced 
flexion and extension. Fractures associated with dislocation may often 
be reduced by first reducing the dislocation and then the fracture. 

When, for any reason, reduction cannot be accomplished and there 
is no contraindication to open operation, perfect reduction and coapta- 
tion of the fracture surfaces should be performed by exposure of the 
line of break, under thorough aseptic precautions, by men trained to 
do this class of surgery. 

The next important feature in the treatment of fractures, after 
proper reduction, is the retention of the fragments in proper alignment 
and the prevention of subsequent deformity. To obtain perfect anat- 
omical as well as perfect functional results should be the aim; the 
accomplishment of the latter, as a rule, will follow the obtaining of the 
former. The statistics of the British and the American Committees 
on Fractures show the dependence of good functional results upon 
perfect anatomical results; and a large percentage of poor functional 
results following poor anatomical results. This means, in the ma- 
jority of cases, faulty reduction, inadequate retention, or lack of 
proper observation and care on the part of the surgeon in charge. It 
should, however, be borne in mind that good anatomical results should 
be striven for in the condition of muscle and tendons as well as in the 



62 TREATISE ON FRACTURES 

hone itself. After reduction has been accomplished, the form of re- 
tentive treatment will depend upon the site and variety of fractures. 
The retention of the fragments and the prevention of subsequent de- 
formity may be accomplished by several means. These methods may 
be divided into temporary dressings, continuous or permanent dress- 
ings, fixation dressings, traction dressings, combined fixation with 
traction, and ambulatory dressings. 

Temporary dressings are used generally to prevent suffering and 
to protect the soft parts from injury by sharp fragments of bone dur- 
ing transportation of the patient to the place of treatment. They are 
used also until the maximum swelling has occurred, or for the retention 
of fragments after reduction until such a time as a continuous or 
permanent dressing may be safely applied. In some fractures a form 
»f fixation may be used as a permanent as well as a temporary dress- 
ing. These cases are mainly those in which extension is not required. 
Temporary dressings as a rule do not prevent recurrence of deformity. 

It must he understood that permanent dressing is not meant a dress- 
ing by which the fracture is excluded for several weeks or days from 
the observation of the surgeon. The shutting up of broken bones in 
fracture apparatus for long periods is to be deprecated. It is a fruit- 
ful cause of undetected deformity, atrophy of muscles, rigidity, and 
ankylosis. After reduction has been obtained, there is generally no 
need of local applications like lead water and laudanum and similar 
remedies. Their efficacy is questionable and they often produce ma- 
ceration of already devitalized skin and subcutaneous tissues. Im- 
mobility and the prevention of muscular spasm are therapeutic agents 
of far greater value than local applications. The use of the ice-bag 
may be of some benefit by lessening the amount of exudate. Its use, 
however, .should be carefully watched, as it may cause areas of necrosis. 

After reduction has been satisfactorily accomplished there are a 
few cases in which retentive apparatus is not needed. These cases are. 
however, rare. A greater safety against displacement of the frag- 
ments and the confidence of the patient will usually be better obtained 
by the u>e of some form of retention. The best fracture dressings are 
those which correct the tendency toward displacement in the individual 
case, preserve anatomical alignment, and prevent over-riding. The 
special tendency toward displacement varies in each case with the line 
and position of fracture and this should he recognized before the dress- 
ing is applied. 

Fracture dressings may be grouped under the following heads : 

(] i Those which secure fixation of the fragments by virtue of 
their inflexibility, and prevent angular or lateral displacement: and in 
which no traction is employed. 

(2) Those in which strong traction with countertraction is the 



GENERAL CONSIDERATIONS 63 

principal feature upon which anatomical coaptation of fragments and 
their proper alignment depend. 

( 3) Those in which moderate traction and indirect fixation are the 
means of retaining efficient reduction of the fragments. 

Very often there may be a combination of several features in the 
treatment used. The simplest methods and apparatus give the best 
results. The various articles used in fracture dressings are rigid 
splints of wood, fibre, aluminum, wire, felt, or pasteboard, applied with 
bandages or adhesive plaster after appropriate padding with cotton or 
sheet wadding, contour splints of gauze stiffened with plaster of Paris, 
silicate of soda, starch, or celloidin; fracture boards, and various 
apparatus for traction. 

The following general rules apply in the application of all forms 
of dressings : 

( 1 ) Do not apply tight bandages next the skin of the limb. 

(2) Do not apply any dressing that is too constricting in char- 
acter or which does not allow for swelling to take place. 

(3) Have all splints well padded and do not depend on pads to 
reduce a deformity. Contour splints moulded to surface are preferable. 

(4) Examine every fresh fracture daily after reduction for about 
a week, and correct immediately any deformity that may occur. Then 
examinations may be made every other day for a week or so. Sub- 
sequently, twice a week will probably be often enough to inspect the 
uncovered region of injury. 

(5) Use general anaesthesia a second time for reduction if the 
X-ray plates taken at right angle do not show good anatomical apposi- 
tion of the fragments. 

(6) It is well to have an N-ray photograph made in two planes at a 
right angle to each other after reduction. 

(7) In fractures of the long bones, immobilize the joints above and 
below the seat of fracture. 

(8) Splints which are not moulded to the part should be more 
carefully and more thickly padded with sheet wadding than moulded 
ones. The latter may fit so well as to practically need no padding. 

(9) Many surgeons fix splints to the part directly with adhesive 
plaster, and do not depend upon bandages alone for keeping splints in 
position. Remember that adhesive plaster may cause dangerous 
constriction. 

(10) In dressing fractures of the extremities, usually keep the 
fingers or toes uncovered, so that lividity, coolness, or cedema, due to 
improper constriction, may be noticed at once and proper measures 
taken to prevent harm. 

(11) Before applying or re-applying a fracture dressing, the skin 
should be washed with soap and water and then washed with alcohol. 



64 TREATISE ON FRACTURES 

95 per cent. I f the skin is hairy it should he shaved before the fracture 
is dressed. 

(i_') Before the retentive apparatus selected for treatment has 
been applied, gentle frictions and light massage, with passive mobility 
of joints, should be employed. This should he done at every dressing. 
Wlcr the first week or so the patient should be encouraged to move 
the joints a little at each dressing. 

Splints. — The most common retentive dressings are made of 
wooden splints, which are appropriate strips of wood padded with 
wool, cotton, or sheet wadding or other soft and elastic material. One 
mi- several may he required to give rigid support to the broken bone. 
For small splints hasswood, three-sixteenths of an inch thick, is very 
satisfactory. For large splints any kind of light wood may be used. 

Wooden splints differ in shape and size in accordance with the 
function which they are to perform. They may be angular when 
applied to a limb so as to control the action of a joint, or straight and 
narrow when used for coaptation around a limb at the seat of fracture. 
Several narrow splints placed parallel to each other may be wrapped 
between layers of adhesive plaster so as to surround the limb for main- 
taining coaptation of fragments, while permanent traction or other 
apparatus may be used to prevent overlapping. The illustrations show 
several varieties of splints. For temporary dressings pillows or folded 
sheets or anything that gives rigidity with softness may be used. 

Special splints of wood have been devised for use in fractures of 
particular bones, as internal and anterior angular and the Stromeyer 
splints for the upper limb, the Agnew patella splint, the fracture box 
fur fractures of the bones of the leg, the double inclined plane, for 
broken shaft of the femur, the Petit elevated fracture box, the Mittel- 
dorf triangle for the humerus, the Volkmann sliding splint for the 
lower extremity, and the Liston thigh splint. In addition to these 
there are many other ready-made splints of w r ood named after the 
surgeons who have devised them to meet the indications in various 
fractures. There are also many forms of carved or moulded wooden 
splints made in different sizes to fit various parts and to be used at all 
ages. Nearly all wooden splints are inferior to plastic splints made 
of gauze dipped in plaster-of-Paris mixture and moulded to the part 
before the gypsum paste has set. These "contour" splints fit and 
need little padding; wooden splints are inferior in this particular. 

Metal Splints. — There is a great variety of metal splints in use. 
They are made of wire or wire gauze, aluminum, perforated zinc or 
tin, or other metals. The most serviceable metal splints are those made 
in sizes suitable for adults or children, and which are sufficiently flexible 
to allow the surgeon to modify their contour to fit the patient's 
requirements. 



GENERAL CONSIDERATIONS 



65 



Moulded Splints. — These are made of leather, poroplastic felt, cel- 
luloid paper, modelling materials, and substances suitable for mould- 
ing when softened by heat or moisture. As a general rule they are 
made in five or six sizes, suitable for adults and children. 

Plaster of Paris. — The best and a very cheap means of dressing 
fractures is by splints, made from plastic material for each patient by 
the surgeon himself. The use of plaster of Paris (gypsum) in the 
construction of splints or encasements for fractures, a means of fixa- 
tion, is now very general. The gypsum powder should be fresh, dry, 
fine, and contain no particles of grit. It is made into a pasty mixture 




Fig. 30. — Method of making moulded gypsum contour splints. 

with water and used to stiffen, by setting, porous materials, such as 
crinoline or cheese-cloth. Accurately fitting splints or encasements 
are thus moulded to the surface of the patient. The material used for 
the foundation of the dressing may be cut into long strips, and the dry 
plaster rubbed into its meshes. These gypsum bandages are then 
dipped into water when required, applied to the limb longitudinally or 
circularly, and given time to harden. The encasement when dry and 
firm is split so as to be easy of removal when the surgeon wishes to 
examine the fracture. The moulded " contour " splints or the case fit 
the surface of the body and can be readily reapplied. 

The best variety of plaster of Paris is dental plaster. The best 
support for the plaster are crinoline (which has been thoroughly 
5 




F.r.. 33. 



Fig 3-4- 



Pu.. 31. — Mr.uMcd Eypsum shoulder-cap. 

;\g gypsum bandages in treating fracture of the clavicle. 
Fig. 3a.— neot outer end of inner fragment, and separation of skin surfaces by layer 

Minn. 

udin. 

■ ndagc applied over muslin bandage giving firm fixation. 



GENERAL CONSIDERATIONS 67 

Pig. 3$. Fig. 36. 




Fig. 37. Fig 38. 

Fig. 35. — Gypsum case applied over flannel bandage for fracture of shafts of both bones of forearm. 
Fig. 36. — Moulded gypsum splint for fractuie of shaft of radius or of ulna. 
Fig. 37. — Anterior and posterior gypsum splints for fracture of lower end of radius. 
Fig. 38. — Method of applying gypsum splints by means of a muslin bandage. 



- 



TREATISE ON FRACTURES 



washed, rinsed, and dried I. cheese-cloth, mosquito netting, or gauze of 
fairly large mesh. Plaster bandages may be purchased ready for use 
or may l>e made by the surgeon or his assistants. A little experience 
will show the proper amount of Paris plaster to be rubbed into each 
bandage, and als sely the bandage should be rolled. The 

- should l>e thoroughly rubbed into the meshes of the cloth, and. 
after being made, the bandages should be separately encased in wax 
paper and stored in an air-tight anil moisture-proof can. Bandages 
should lie made oi various widths, the most useful being two. three. 
ami four inches. In making large moulded plaster splints the size and 

Fig 30. Fig. 40. 




- 

:icarpai 

i covered may be first ascertained by making 
a model in paper. About ten to fifteen layers of netting should then 
l>e cut a little larger than the model and thoroughly impregnated with 
the powdered gypsum. These layers are laid one upon another 

and a- Another v jper model on the 

table, cover it with twelve to fifteen layers of a plaster bandage un- 
pack and forth, and while it is still wet apj ie part 

may be -imply poured on layei 
gauze. 

andages the part to which the encasing 
should befii - lannel 

ng. Then a one-inch wide strip of lead. 



GENERAL CONSIDERATIONS 



69 



greased and wrapped in paraffine paper, should be placed lengthwise 
over this layer. Above the metal the plaster bandages are applied. 

Fig. 41. 





Fig. 42. 

Fig. 41. — Method of holding lower extremity for application of circular gypsum case in the treat- 
ment of fracture of the leg. If there is spasm of calf muscles, hold knee flexed. 
Fig. 42. — Finished gypsum case applied to lower thigh, leg, and foot. 

The dried dressing may be readily split with a knife over the lead 
without cutting the patient's skin. Lead tape is flexible and convenient, 
but is not necessary. If it is wrapped in paraffine paper before the 



70 TREATISE ON FRACTURES 

bandages arc applied, it can lie readily withdrawn after the dressing 
is split. Encasing gypsum dressings applied to the extremities should 
be cut down both sides immediately after application; on no account 
should a circular plaster-of -Paris bandage be applied as a primary 




Fi<;. 44. 
Fm.*. 4 ( and 14. — Moulded gypsum splints for fractures about the ankle-joint. 

splint, unless all inflammatory swelling has occurred and is subsiding. 
\ good rule to adopt is never to apply a circular gypsum dressing until 
after the fifth day unless it is cut down both sides immediately and 
.ill possible constriction is removed. 



GENERAL CONSIDERATIONS 71 

In using the dry plaster-of-Paris bandages there should be placed 
five or six of them in a pail of lukewarm water, which should be deep 
enough to cover them completely. It is not necessary to place salt or 
alum in the water to promote hardening of the plaster. After all air 
bubbles have escaped, the bandages should be gently squeezed from 
both ends to express the excess of water and applied without con- 
striction. Each succeeding layer should be carefully rubbed against 
the one underneath; and the part should be held by one or two assist- 
ants in a corrected position, so that the plaster will set without any un- 
due indentations, finger marks, or cracking. The rubbing in of addi- 
tional plaster-of-Paris to the outside of the bandage is not advisable, 
because it does not increase the strength of the dressing much, but 
greatly adds to its weight. All bony prominences should be especially 




Pig. 45. — Moulded gypsum splint for fracture of the metatarsal bones. 

well padded, the fingers or toes should be left uncovered for examina- 
tion, and the encasement may be split down both sides immediately 
after application. The two parts should then be held together by a 
gauze or cotton roller bandage. The thickness of the case should de- 
pend upon the part to which it is to be applied and the amount of 
strain that may be brought to bear upon it. Its wall may be materially 
strengthened without greatly increasing its weight by imbedding be- 
tween its layers narrow strips of aluminum, zinc, or wood at the points 
where undue strain will take place. If for any reason it is deemed 
advisable not to cut the case immediately after its application, it may 
be readily cut at some future time by moistening the line of incision 
with warm water, vinegar, or water and hydrogen peroxide combined. 
The best instruments for cutting an encasement are a pocket knife, any 
knife with a pruning blade, scissors with serrated edges, and especially 
designed saws. 



7 _, TREATISE ON FRACTURES 

The best way of using plaster of Paris as a fixation dressing in 
open fractures is to apply it in a circular manner and, after the plaster 
has become firm, to cut one or more windows to give access to the site 
of the external wound. If this wound is very extensive and a large 
window is required, the plaster case may he strengthened by incor- 
porating strips of zinc, tin, or iron along its side ; or the site of the frac- 
ture may he left entirely free, and the plaster applied above and below 
so held by suitable metal connections or with specially designed wire 
splints as to support the broken hone in its anatomical relations. 

At times it may he considered advisable to surround the window 
edges in a gypsum case used for an open, or compound, fracture with 




PlO. 46. — Method of applying traction to leg and thigh. The Buck's extension apparatus. Sand 
bags may Ik- placed at both sides of the extremity, or. better, an external T or Liston splint to 
prevent eversion or inversion. Long, narrow boxes to hold bricks on edge are better than sand bags. 



a covering to prevent its being softened. This may be neatly done by 
coating the edges and plaster near the edges with a solution of rubber 
in chloroform and afterwards shellacking the entire case. This will 
allow frequent irrigation of the wound, and still preserve the integrity 
of the c.-^e. 

The great advantages of gypsum splints and encasements are that 
they accurately lit the contour of the limbs or body to which they are 
moulded, and that the materials are cheap and obtainable in all local- 
ities. All that i- essential is a dozen layers of moscpiito netting, dry 
plaster-of-Paris powder, and water. These things are to 1*2 found in 
every town throughout the civilized world. The surgeon needs only 
to cut the netting into pieces, smear them with a paste made of the 
plaster and water, mould them to the patient's surface, let them dry. 



GENERAL CONSIDERATIONS 73 

remove them, trim the edges, and he has rigid splints of proper size 
and shape. 

Extension or Traction Dressings and Methods. — Traction, 
often called extension, has been used in the treatment of certain fract- 
ures for a long time. Its object is to overcome muscular spasm by 
exerting a longitudinal pull on the fragments, and to correct over-rid- 
ing, as well as lateral and rotary deformities, due to muscular re- 
traction. Its use in the treatment of fractures is especially well known 
in the treatment of fractures of the femur. It was first used by Gross 
in 1830, in the form of an adhesive plaster dressing with weights ; 
and later it was popularized by Gurdon Buck, whose name has been 




given in America to this form of dressing (Fig. 46). During the last 
twenty-five years traction in the treatment of fractures has been 
developed on the continent of Europe, primarily by Von Bergmann; 
and in late years has been especially perfected by Bardenheuer of 
Cologne, by Steinmann of Berne, and by Zuppinger of Zurich. These 
last three authorities use methods of traction or extension differing 
radically in technic and application. Their methods have been exten- 
sively adopted by other European surgeons. A short description of 
the method is as follows : 

Bardenheuer 's Method (Fig. 47). — Bardenheuer claims that the 
principal cause of deformity in fracture is general retraction of all 
tissues surrounding fractures, and particularly the muscles. As a re- 
sult of the blood infiltration of the soft parts, and especially the 



74 



TREATISE ON FRACTURES 



muscle, there is a secondary tissue change of the entire exudate about 
the fracture, which is most marked in the muscles and results in 
retraction. 

The ordinary method of extension overcomes only the normal mus- 
cular contraction. I'.ardenheuer considers that the ordinary use of 
weights is not sufficient, and that extension should be positive and 
sufficient so that not only is the normal muscular contraction over- 
come, but that the retracted muscles should be permanently stretched. 
The principles of his method combine traction in a longitudinal direc- 
tion with counter-traction, and traction in transverse, rotary, and 
oblique directions, as required. By these various forms of extension 

Fir. 48. Fig. 49. 




-Thos. Bryant's method of vertical traction especially useful in fracture of femn 
PlC. 49. — Oblique traction used for sub-trochanteric fracture of femur. 

he claims to he able to overcome all forms of longitudinal, lateral. 
rotary, and over-riding displacements, and to obtain not only good 
functional results, but also good anatomic apposition of the fragments. 
Bardenheuer employs his method of extension in fracture of the upper 
and lower extremities. The method, which can scarcely be used out- 
side a well-equipped hospital, is complicated and requires careful 
supervision daily by the surgeon in charge. The patient is compelled 
to rest in bed for at least three weeks. It demands expensive apparatus 
and the results are. as a rule, no better than those obtained by simpler 
methods. Judging from the results of I'.ardenheuer and his pupils 
from a study of his X-ray photographs, one is led to conclude that 
anatomical apposition of the fragments is not as frequent as one would 
exped and that functional results may he unsatisfactory. This method 



GENERAL CONSIDERATIONS 



75 



has not been popular in our American hospitals, probably because of 
the absolute rest in bed enforced in all cases and the careful daily 
supervision required by the complicated apparatus. 

An important outcome of Bardenheuer's teaching has been the 
fuller recognition of the necessity of securing for fractures careful and 
frequent attention from skilled surgeons; and therefore the desirability 
of special wards for these injuries in hospitals. The method of dress- 
ing is less important than the conscientious care of a surgeon with 
mechanical instinct. 

The vertical traction method suggested by Thomas Bryant, especi- 
ally for children, though it is available for adults as well, or its modi- 
fication, oblique traction, in appropriate cases, as shown in the illus- 




nf femur and tracti 



trations and used by one of us in fractures of femur, will often allow 
the rejection of complicated apparatus. 

The objections to his methods are : ( i ) The absolute rest in bed 
required for nearly all fractures treated by his method of extension. 
(2) The constant supervision required by his various devices, many of 
which consist of very complicated combinations of pulleys, weights, 
and means of fastening the apparatus to the patient's limb. (3) The 
occasional relaxation of joint structures which have been reported fol- 
lowing the use of the heavy extension weight. (4) The failure to 
obtain perfect anatomical results, shown by Bardenheuer's X-ray pho- 
tograph. In some instances these are not as good as may be obtained 
with safety by direct fixation under operative treatment. With poor 
anatomical results it follows that functional results probably will be 
poor. 



76 TREATISE ON FRACTURES 

Steinmcmn's Method of Nail Extension (Figs. 50 and 51).— This 
method was first described by Steinmann in 1907, although it had 
previously been employed by Codivilla in Bologna in 1903. Steinmann 
claims that his method differs from that of Codivilla in that the latter 
extension by placing nails in the os calcis. Steinmann obtains 
traction by inserting nails in the distal fragment of the broken bone, 
and its application is not limited to fractures of the lower extremity. 

Steinmann secures traction in fractures of the long bones by the 
insertion of a steel nail through the epiphyseal end of the distal frag- 
ment, and, by means of an appropriate apparatus attached to the nail, 
extension is made. Steinmann employs this method wherever ex- 
tension is needed. Fie claims that there is no necessary irritation at 




the points where the nails enter the skin, that no unusual precautions 
to prevent infection are necessary, and that less weight is necessary 
than that required in the extension method with adhesive plaster. He 
states that with the use of semi-flexion even less weight is required. 
Steinmann has used these nails in the os calcis for fracture of the 
malleoli, in the malleoli or through the tibia in fractures of the bones 
of the leg, in the condyles of the femur for fractures of the shafts or 
neck. They have also been used in fractures of the humerus and have 
Keen employed by Wilms in the reduction of congenital dislocation of 
the hip-joint. Various modifications of the method have been made 
by Wilms, Becker, Vockler, Heinemann, Anschiitz, and others. Their 
modifications consist in changes in the form of the nail, the method of 
applying extension to the nails, or in the method of inserting the nails. 
The procedure is also of value in reducing old fractures, in delayed 
union, in compound fractures, and as a preparatory method to the 
open direct fixation of the fragment. 



GENERAL CONSIDERATIONS 77 

The disadvantages of the method are: The possibility of infec- 
tion, by which the nails at times become loosened very rapidly, and the 
constant supervision. Cases of infection following its use have been 
reported by Anschiitz, by Morian, and others. Other disadvantages 
are the possibility of over-correction with the formation of false joints, 
the possibility of gangrene of the skin at the point of insertion of the 
nails, and the probability of interference with the epiphyseal cartilage 
and subsequent growth of the bone in children. 

Technic of Application of Steinmanns Nails. — Under proper sur- 




FiG. 52. — Zuppinger's method of traction and support for fracture of the femur. 

gical precautions nickel-plated round steel nails are driven into each 
condyle in fracture of the femur in an oblique direction. At times it 
may be advisable to use the special drill recommended for drilling 
appropriate holes for these nails. To the head of these nails there is 
attached a special apparatus resembling an ice-tongs, and extension 
is applied directly to this. During the first week 25 to 30 pounds are 
used, and later 10 to 18 pounds. Reposition of the fragments usually 
occurs by the sixth day, and in some cases over-correction or a com- 
plete diastasis may occur. After reduction the amount of weight may 
be reduced. 

There is no doubt that this method is of especial value in certain 



78 TREATISE ON FRACTURES 

forms of fracture, where reduction and anatomical apposition cannot 
be i tbtained by other means. The objections to its use are noted above. 
That it is a method for hospital use alone cannot be too strongly 
stated. It requires constant supervision. 

Zuppinger's Method of Extension (Figs. 52 and 53). — In 1898 
Kronlein, before the German Surgical Congress, demonstrated a 
method of extension for the treatment of fractures of the thigh and 
leg. This method was devised by Zuppinger, and its principle depends 
upon an old idea first brought forward by Pott in 1768, that of 
producing relaxation of the displacing muscles by placing the joints 
involved in a position to relax the muscles. This principle of relaxa- 




tion of the muscles is also used in Smith's anterior splint and in the 
Hodgen splint. Zuppinger considers that the displacement of the 
fragments in a fracture is due to the elastic pull of muscles and that in 
placing the hi]) and knee in a position of semi-flexion almost all of 
tins tension is relaxed and what still remains may be overcome by a 
slight weight, lie also believes that there is considerable damage done 
lo muscles and joints by the usual methods of weight extension, and 
that the period of convalescence is longer in these cases. 

Zuppinger's apparatus consists of a baseboard, a groove for the 
thigh, a groove for the leg, a footboard with screws for adjustment, 
and another for regulation of the amount of flexion. Its principle is 
similar to Petit's fracture box. The principle is represented by the 
illustrations. Treatment on this principle has been carried out bv a 



GENERAL CONSIDERATIONS 79 

number of the German surgeons, and excellent results have been 
reported by Henschen, by Wettstein, by Montadon and Vogel. 

The disadvantage of this method is that of the two above de- 
scribed. It requires very careful supervision daily and a considerable 
amount of mechanical skill is required for its proper application. It is 
doubtful whether better results are obtained by this method than by the 
less complicated methods in tise in America. Kronlein claims that by 
Zuppinger's method of extension good anatomical as well as good 
functional results are obtained. 

Open. (Compound) Fractures. — The treatment of open fract- 
ures should be conservative, and in each case an endeavor should be 
made to give a good result with the sacrifice of the smallest amount of 
tissue. As a rule open fractures are seen soon after the time of injury, 
and occur in injuries of the limbs rather than of the trunk. They may 
be divided into four classes : ( I ) those in which there is not only 
great pulpefication and destruction of bone, but also crushing and 
devitalization of the soft parts; (2) those in which there is marked 
comminution of bone, moderate destruction or crushing of soft parts, 
no interference with the main blood supply, and a small external 
wound; (3) those in which there is a fairly large wound, perhaps near 
the joint, and in addition protrusion of one or more fragments through 
the wound with considerable soiling of their ends; and (4) those in 
which there is only a small external wound with very little soiling of 
the depths of the wound. 

In the first class amputation is generally the only thing to do. As 
a rule there is interference with the main blood supply to the extremity, 
the soft parts are widely devitalized, and the entire wound so soiled 
that it is impossible to render it sufficiently aseptic to expect union. 
Such injuries require amputation, or should be treated as septic osteo- 
myelitis complicated by fracture. 

In the three other classes of open fracture a great deal can be done 
by conservative surgery. The skin should be shaved and washed with 
soap and water, and great care be taken not to contaminate the depths 
of the wound. When the surgeon feels sure that contamination has 
taken place the wound should be thoroughly irrigated with a 2 to 5 
per cent, alcoholic solution of iodine. The wound and surrounding 
skin should then be cleaned with 70 per cent, alcohol, and the wound, 
if large, partially closed, and drainage, in the form of folded rubber 
tissue, introduced to its bottom. A dry sterile dressing should then 
be applied and the part immobilized in a plaster-of-Paris case, in 
which a window has been cut over the seat of drainage. Unless there 
is some indication of trouble, such as continued elevation of tem- 
perature, pain, or a feeling of local heat, the wound should not be 
dressed for several days. If there is any indication for examining the 



TREATISE ON FRACTURES 

wound it should be uncovered at once. and. if found infected, it 
should be freely opened for drainage, and thoroughly irrigated daily. 

It is probably seldom wise to suture or plate fragments at the time 
of the primary dressing of an open fracture. General anaesthesia 
should be the rule when cleansing and reducing severe injuries, be- 
cause unless the disinfection is thorough and the reduction of frag- 
ments satisfactory the convalescence will be long and the anatomical 
result poor. The primary dressing of an open fracture determines 
usually the fate of the patient. If asepsis is obtained, the injury 
progresses almost like a closed fracture. Otherwise prolonged sup- 
puration is probable; and death or amputation not unlikely. If large 
hematomas are present, they may be opened. If the ends of frag- 
ments are contaminated, they should be thoroughly cleaned with anti- 
septics, i »r perhaps excised. Portions of bone with attached periosteum 
should be left intact. The less operative interference performed at 
this stage, the better. The wounds are more or less infected, and while 
in many cases the infecting organisms may not be virulent, in some 
the forms of infection are extremely so. Operative extension of the 
infected wound may. by opening up new paths of infection, lead to 
disaster. If bone suture or other methods of direct fixation have to be 
employed, it may be well to wait a week or more. Conservative treat- 
ment with good circulation of the part should take care of many 
organisms, and more perfect reduction be gained by later operation. 
The most frequent forms of infection are virulent strains of strep- 
tococci, staphylococci, aureus and albus, tetanus bacilli, and Bacillus 
aerogenes capsulatus. The European war has furnished many examples. 

A very important step in the treatment of open fractures badly 
contaminated with street dirt may be the prophylactic use of antitetanus 
serum. When circumstances have prevented thorough disinfection 
of the wound soon after its receipt, a subcutaneous injection of 1500 to 
3000 units of the serum may be given as a routine measure. Many 
open fractures, however, are received under conditions that make them 
no more likely to be infected with tetanus bacilli than other wounds. 
Those which have been soiled with material liable to harbor tetanus 
micro-organisms should be viewed with suspicion, as is the case with 
certain gunshot wounds. 

The use of metal plates or other forms of internal fixation is not 
advisable at the timeof primary dressing. In these cases, forms of 
direct fixation of the fragments to obtain anatomical alignment prob- 
ably should be used only at a later ]>eriod. when the pyogenic or other 
infection has le-s opportunity to exert its harmful influence and when 
it i- evident that malunion is taking place. They should not be used in 
the presence of marked infection. Direct fixation of the fragments is 
contraindicated became of possible infection of the tissues, especiallv 



GENERAL CONSIDERATIONS 81 

of bone, of the length of time required, of the increased traumatism 
done to already devitalized tissues, and the possibility of extensive 
destruction of bone from stripping up of periosteum. 

Important words on the treatment of open fractures are those of 
Rinmann, of Klauber, of W. L. Estes before American Surgical Asso- 
ciation, and of Beavis and Souttar. 

Massage and Passive Motion in the Treatment of Fract- 
ures. — Recent experience in the treatment of fractures and the 
knowledge gained by frequent X-ray observation are making radical 
changes in methods of treatment, and have greatly modified many pre- 
conceived notions regarding the pathology and treatment of fractures. 
Surgeons are now abandoning prolonged immobilizing dressings, 
and in their place are using methods of treatment which allow a 
better circulation, less muscular compression, early careful massage, 
and earlier joint motion. Dressings are not so cumbersome, they 
are changed more frequently, the muscles are more frequently mas- 
seed, so that by the time good firm union has taken place the muscles 
and joints are in more or less normal condition. With infrequent 
dressings and prolonged immobilization, loss of muscular tone, muscu- 
lar atrophy, and restriction of the normal motions of the joint and 
undetected deformity are quite common. Massage hastens the absorp- 
tion of exudate, prevents stiffness and atrophy of muscles, and main- 
tains a more normal condition of the circulation. Daily removal of 
dressings and light massage, if carefully performed, will be beneficial. 

In addition, slight passive motion of the joint in proximity to the 
seat of fracture should be made daily. Light massage and passive 
motion should be started in suitable cases immediately. During the 
manipulations the part should be carefully held by an assistant. The 
motions at first should be very gentle, short in duration, without pain. 

Later, when the callus has become firmer, the interval of time may 
be increased and the massage may be more energetic in character. At 
no time should the manipulations be violent enough to produce dislo- 
cation of fragments. Voluntary motions should be encouraged, and 
dressings may be, in many cases, so applied as to permit of muscular 
movement without doing any damage to the position of the fragments. 
In cases of fractures involving joint surfaces this early massage, and 
especially passive motion, are of the utmost importance. By their use 
the surgeon may obtain quite a wide range of motion, which would be 
impossible with other methods. The only danger to early massage 
and passive motion is displacement of fragments. This should always 
be borne in mind, and there are certain classes of fractures where this 
may be disregarded. The massage should not be the vigorous form 
often used by professional masseurs for other purposes. Gentleness 
must be its chief characteristic. The principle of early massage and 



TREATISE ON FRACTURES 

passive motion in the treatment of fractures had for its greatest ex- 
ponent Lucas-Championniere. For many years he advocated these 
methods, and recommended the disregarding of splints to a great ex- 
tent in fracture treatment. He was an earnest opponent of prolonged 
immobilization : and was probably led to take an extreme position, be- 
cause he saw the had functional and had anatomical results due to it. 

Early light massage, early passive and active motions, with com- 
paratively simple external fixation apparatus, will usually give better 
results than the immobilization method as used by many practitioners. 
It is the adherence to the antiquated immobilization method without 
passive and active mobility which has given Fane and his followers 
their chief argument in favor of almost universal treatment by plates 
and screws. 

Functional Treatment of Fractures. — By the functional 
treatment is meant the use of all means which will preserve the circu- 
lation, retain normal muscular tone and joint function, and help in 
early callus formation. It seems prohable that in many instances im- 
mobilization is too severe, the use of the fixation dressing too pro- 
longed, and proper supervision of the fracture greatly neglected. It 
is l)elieved that there are many fractures which, if properly reduced, 
will remain in correct anatomical position with a minimum of splint- 
ing. In conjunction with shorter periods of immobilization and less 
cumbersome dressings, the functional recovery of the part should be 
perfect by the time good tony union of the fragments has occurred. 
This often may be accomplished by early light massage with passive 
and active motion. What can he done thus is seen in the treatment 
of the classic fracture of the lower end of the radius conducted on 
these lines. Complete reduction, fixation upon a contour splint, which 
does not limit voluntary flexion and extension of the fingers, combined 
with light massage and occasional passive as well as voluntary move- 
ments of the wrist from the beginning, and discarding the splint at 
the end of two and a half weeks, will seldom fail to result in five or six 
weeks in a good functional and anatomical cure. Deformity of the 
radiocarpal region after impacted fracture, in which extension and 
flexion of the wrist are limited, and in which there is marked abduction 
of the hand combined with (edema of the wrist region and stiff fingers. 
would he very infrequent. It is adherence to old ideas of the pathology 
of this injury and unscientific clinging to prolonged immobilization 
that give rise to the had results so often seen. 

In addition to the suggestions made above, there are other means 
of improving the function of the part, such as electricity and hot 
water bathing and in delayed union, congestive hyperemia locally; and 
appropriate treatment for general conditions, such as tonics, thyroid 



GENERAL CONSIDERATIONS 83 

extract, antisyphilitic remedies in those showing a positive Wasser- 
mann reaction, with fresh air and sunlight. 

The use of passive hyperemia by means of a rubber bandage about 
the limb in cases of delayed union in fractures was employed by 
Roberts and its results published in 1898, and also by Helferich in 1887. 
Both, it is believed, anteceded Bier in using it in fractures, although he 
was using it in other conditions in 1892. 

Ambulatory Treatment of Fractures. — The advisability of 
allowing patients to walk during the treatment of fractures of the 
lower extremity depends upon several factors. There are fractures in 
which the ambulatory method is clearly contraindicated ; on the other 
hand, there are many, especially of the upper limb, which may be 
treated in this way. without imperiling an expected good result. Again, 
there are certain cases in which the treatment of the fracture by any 
formal method is of secondary importance, because the danger of im- 
pending complications interrupting the recovery or ending the life of 
the patient is of greater moment than the securing of a good cure of 
the fracture. The disadvantages of the ambulant method of treatment 
are the difficulty of a proper application of the required dressing, and 
its more careful and constant supervision than when the patient is kept 
quiet in bed; complications arising at the seat of fracture are more 
frequent ; it is a form of treatment not suited for the general prac- 
titioner; in many fractures it is impossible to maintain reduction of the 
fragments if the patient is moving about on his feet. Therefore, in 
these injuries, ambulatory exercise may only be used with safety at the 
end of several weeks, when union is becoming firm. As a subsidiary 
form of treatment it is often convenient, comfortable and safe. 

The advantages of ambulant treatment may be summarized: Pul- 
monary complications are less, even in the aged ; delirium tremens is not 
so frequent; muscular atrophy and rigidity of joints are not so great, 
and callus formation is very abundant and rapid. These remarks apply 
especially to fractures of the lower limb. It is distinctly contraindicated 
as a rule in fracture of the femur until at least the third week, and in 
fracture of the shafts of the bones of the leg until the same time has 
elapsed. After this time it may be used if it is possible to maintain 
good apposition of the fragments by an appropriate external dressing. 
When fractures are fixed by plates and screws, the ambulant method 
may be instituted earlier as a part of the management of the injur}'. In 
fractures about the ankle-joint, this form of treatment may be used 
from the beginning, or at least at the end of four or five days. In frac- 
tures of the humerus it may generally be used, even in cases requiring 
extension. About the only cases that prohibit its use are fractures of 
the surgical neck of the humerus requiring extension in the abducted 
position. In a great majority of cases not requiring extension, the best 



s4 TREATISE OX FRACTURES 

and cheapest form of dressing will be die plaster-of-Paris case and 
crutches. In those cases requiring extension there are many well-recog- 
nized and appropriate forms of extension braces obtainable: and their 
number may be supplemented by specially constructed ones to suit the 
particular fracture under the surgeon's care. 

Wearing the sole oi the shoe of the well leg one inch higher than 
that on the injured limb and using long crutches will permit the patient 
t<> walk in the open air without risk of bearing weight on the seat of 
fracture. Keeping the foot of the unsound limb off the ground may 
also be secured by flexing the knee of the injured side by means of two 
leather straps around thigh and calf, fastened together with a short 
strap under the popliteal space. Then it is not necessary to raise the 
other shi >e or lengthen the crutches. Early resumption of exercise is 
often neglected when easily practicable by such devices. 

Functional relaxation of displacing muscles, plastic contour splints. 
properly applied traction, judicious mobilization and massage asso- 
ciated with a knowledge of anatomy, a mechanical sense and assiduous 
attention are the requisite therapeutic and professional elements for 
non-operative management of broken bones in the extremities. Sim- 
plicity in fracture dressings is of importance. If elaborate apparatus 
is required, the patient would probably be better served by the operative 
method of direct fixation at the hands of a skilled expert in surgery. 



CHAPTER II 

THE OPERATIVE TREATMENT OF CLOSED FRACTURES 

The treatment of fractures has not received, by the general surgeon 
during the past fifteen years, the attention that it deserves. Abdom- 
inal, pelvic, cranial, and thoracic surgery and their development have 
been of utmost interest and have occupied the time of general surgeons 
during these years. The subject of fractures has been neglected; the 
orthopaedists have developed the surgery of joints, tendons, and de- 
formities, but the profession at large has been content with the teach- 
ing of twenty years ago in regard to the treatment of fractures. Good 
functional results were the subject of congratulation. Proper ana- 
tomical apposition of the fragments was not considered necessary in 
fractures, and in many it was rarely attempted. If the patient had a 
fair functional result and a not too evident deformity, the anatomical 
position of the fragments was often disregarded. The development 
and perfection of radiography have shown how poor our work has 
been. It has taught that perfect anatomical apposition of fragments 
was rarely obtained, that exuberant callus was the frequent condition, 
that many text-book methods of treatment of certain fractures were 
absolutely obsolete and were at times harmful, that the lines of fracture 
were not always as they were thought to be, and that many supposed 
sprains and contusions about joints are fractures, sprain-fractures, or 
avulsion of tubercles and muscular attachments. 

The Rontgen ray, in addition to helping us in diagnosis, is of 
great value in the subsequent treatment. By its use we are able to 
judge of the continued approximation of the fragments, of the amount 
of callus produced, and of the extent of union present. The use of 
the Rontgen ray is wise, not only in cases of suspected fracture ; but the 
majority of sprains, so called, should be radiographed. By making 
this the customary rule, one not only is able to make a better and clearer 
diagnosis and use more intelligent treatment, but a great many supposed 
sprains will be found to be fractures. This is particularly so of in- 
juries about the wrist-joint. Many fractures of the small bones, 
particularly of the carpals, and unsuspected sprain-fractures will be 
recognized. In taking radiograms of suspected fractures it is advis- 
able to have a primary radiogram made before reduction, one imme- 
diately after reduction, and a third about one week to ten days after 
the time of reduction. At each X-ray examination two radiograms 
should be made, one at a right angle to the other, so that the existence 

85 



86 TREATISE OX FRACTURES 

of a fracture and the position of the fragments will be recognized. An 
anteroposterior and lateral view should thus be made, when feasible. 

The dangers of infection of bone in the open treatment of closed 
fractures have been a constant menace to surgery and have been 
dwelt upon in text-books for years. Yet operations on tumors of bone 
and exostoses, and osteotomies for osteomyelitis and periostitis have 
been unhesitatingly performed. That this teaching has been fallacious 
is shown by the results obtained to-day in all classes of bone surgery 
performed under the proper aseptic precautions. While infection of 
hone is a serious condition, it should not follow a properly performed 
operation in cases of fracture any more frequently than after abdom- 
inal operations or procedures on other structures. 

From experience it can be stated that the cases of fracture requir- 
ing operation are comparatively few. There are certain closed frac- 
tures which always call for operative interference, and there are some 
cases which are followed by better anatomical and functional results 
by operative fracture treatment. Open operation has long been used 
to cure non-union, vicious union in old fractures, and in those recent 
cases in which failure of the usual methods of reduction has occurred 
or the use of approved appliances to retain the fragments of bone in 
apposition has resulted in failure. The cases most urgently requiring 
operation are those in which the deformity cannot be reduced, or, if 
this is possible, in which proper approximation cannot be maintained; 
severe open or compound fractures; compound comminuted fractures 
in which it is impossible to properly replace the fragments; and cases 
of non-union, mal-union, and exuberant callus. In many cases in which 
there is marked comminution of the fragments and in oblique and 
spiral fractures of the long bones, where reduction is impossible, opera- 
tive intervention is justified. Many of the deformities, pseudo-arthro- 
ses, loss of function, and disability for work following fractures will 
thus be avoided. The unsightly deformities which so seriously mar 
the proper contour of the parts and predispose to refracture, excessive 
callus, and loss of function will be prevented. 

Fractures complicated by severe injury to adjacent organs demand 
operation. Under this heading may be included fractures in which 
pressure is brought to hear on neighboring viscera, nerves, and blood- 
vessels, fractures associated with dislocations, and articular fractures. 
The direct results of improper approximation of fragments are exub- 
erant callus, non-union and malunion. Nerves, blood-vessels, and 
tendons are liable to he involved in this excessive attempt of nature to 
repair the loss of bony continuity. Involvement of such structures is 
often seen in the neuritis, .edema, and plastic involvement of tendons 
and tendon sheaths following malunion. When excessive callus is 
fanned at the scat of fractures involving joints, impairment and at 



OPERATIVE TREATMENT OF CLOSED FRACTURES 87 

times total loss of function is the result. Excessive callus is the result 
of imperfect approximation and failure of accurate retention of the 
fragments. 

Contraindications to Operative Treatment of Fractures. — These 
may be grouped under four headings : ( i ) those due to the fracture ; 
(2) those dependent upon the patient's general condition, (3) those 
pertaining to the operator; and (4) those relating to the environment. 

The contraindications to be found in the fracture itself are few. 
They are generally infection of neighboring structures, and an in- 
fected abrasion of the skin. The contraindications to operation de- 
pendent upon the patient's general condition are cardiac, renal, arterio- 
sclerotic, and pulmonic in nature. Any serious involvement of these 
systems calls for the greatest care in deciding for operative interven- 
tion. Patients subject to chronic alcoholism and syphilis are poor 
risks for operative procedures. 

The contraindications pertaining to the operator himself are very 
important. Operations upon bone require not only the most scrupu- 
lous aseptic care, but a great degree of manual dexterity as well as 
speed. The -greatest source of infection following operations upon 
fractures are infection from without carried from the skin into de- 
vitalized structures, prolonged handling of the tissues, bruising of the 
soft parts, inaccuracy in apposition of fragments, mal-application of 
the internal fixation apparatus, the presence of dead spaces filled with 
oozing blood, and failure of complete hsemostasis. Anyone attempt- 
ing to perform these operations must have a sound aseptic technic, 
marked dexterity, surgical judgment, mechanical skill, and, above all, 
must produce as little traumatism to the soft parts as possible. Other- 
wise his efforts are doomed to failure. 

The contraindications from environment are several. One should 
perform these operations only under the very best conditions. They 
should not be done where aseptic methods are doubtful. They should 
be performed only in the best equipped aseptic operating rooms, with 
assistants trained in this special class of work, and there should be at 
hand, not only the ordinary instruments used in bone surgery, but in 
addition such special instruments as may be needed to manipulate frag- 
ments into place with the smallest possible amount of damage. In 
addition a proper mechanical apparatus should be at hand for extension. 

Classification of Cases Designated for Operative Treatment. — The 
Committee on the Treatment of Fractures of the British Medical Asso- 
ciation adopted the following classification in their compilation of 
statistics for their report. It is as follows : 

( 1 ) Those cases in which operation is decided upon at once and 
is performed as soon as possible (Class A). 

(2) Those cases in which operation is performed on account of 



S8 TREATISE ON FRACTURES 

failure to obtain and maintain accurate apposition by means of ex- 
ternal mechanical appliances (Class B). 

(3) Those cases in which operation is performed for non-union, 
for deficient union, or for faulty union, whether in progress or com- 
plete ( Class C). 

In addition to these classes there are those cases of fracture which 
are treated by non-operative methods, but in which there are sub- 
sidiary operations required. These operations consist of tenotomies, 
osteotomies, excision of joints, removal of callus or projecting frag- 
ments, freeing of nerves. These cases cannot be classified with the 
above. 

Indications that Call for Operation. — The results desired in the 
operative treatment of all fractures are: proper reduction and ap- 
proximation of the ends of the fragments ; the prevention of subse- 
quent deformity ; the retention of alignment of the fragments ; the pre- 
vention of pseudo-arthrosis, non-union, mal-union and deformity; the 
retention of muscular tone and normal joint movements above and 
below the seat of fracture. 

.Many conditions prevent the accurate adjustment of the fragments 
in fracture of the long bones. They may not only prevent reduction, 
but are often the cause of delayed union, neuritis, oedema, paralysis, 
muscular atrophy, loss of function, and at times absolute incapacity. 
The most frequent obstacles to the complete reduction of the 
fragments and their permanent retention are: muscular spasm; the 
interposition of soft parts, as muscles, tendons, nerves, blood-vessels 
and fascia; infiltration of the surrounding tissues; the piercing of 
adjacent muscles and fascia by the sharp ends of the fragments; the 
interlocking of fragments caused by the primary violence; the short- 
ening due to the over-riding of the fragments; rotation of a detached 
fragment: the difficulty of preserving the anatomical apposition until 
some form of external fixed dressing has been applied.' 

Muscular spasm, infiltration of the soft parts, and interlocking of 
the fragments may be overcome by general anaesthesia, manipulation 
and traction. Repeated gentle massage will frequently lessen greatly 
the spasm and infiltration. The interposition of the soft parts be- 
tween the fragments may be removed by careful manipulation and 
tion. One should be extremely careful not to leave any of the 
sofl 1 'arts between fragments, as there may result non-union and actual 
pseudo-arthrosis. I he shortening due to over-riding of the fragments 
may at times be difficult to Overcome. In recent fractures it can be 
overcome by traction and counter-traction properly applied, under 
anaesthesia, or by continuous traction continued for several days and 
accompanied by gentle massage, or by tenotomy. 



OPERATIVE TREATMENT OF CLOSED FRACTURES 89 

In cases of several weeks' or months' standing, mechanical methods 
necessary for the correction of the over-riding, unless carefully applied 
and adjusted, may cause marked injury to the soft parts at their points 
of application. The traction and counter-traction are to be made after 
exposure of the fracture by the incision. Manual traction is generally 
inadequate. There are various forms of traction apparatus in use. 
The compound pulley with clove hitch or Levis plate, is sufficient, but 
special tables are made. Accurate adjustment of the fractured ends 
requires, in addition to traction and counter-traction, some form of 
clamp or forceps. The most feasible are. those devised by Lane, Sher- 
man, Lowman, and Lambotte. Various forms of levers are also neces- 
sary in getting accurate adjustment. 

Time of Operation. — Class A. — In certain fractures in which it 
is known from experience that proper reduction and retention can- 
not be obtained by non-operative means, it is advisable after prelim- 
inary radiographic examination to operate immediately, provided the 
patient can be assured of an aseptic procedure, is free from grave 
organic disease, and has had no appreciable shock at the time of the 
accident, or, if so, has recovered. Spiral and oblique fractures of the 
tibia, supracondylar fractures of the femur, fractures of the shaft of 
the femur at the junction of the tipper and middle thirds, fractures of 
the olecranon, patella, calcaneum, with separation of the fragments, 
are instances. A good index of the amount of shock present is the 
pulse, blood-pressure, and temperature. By immediate operation re- 
duction of the fragments can be more readily accomplished, blood clots 
evacuated, infiltration of the soft parts, the formation of fibrous tissue 
between the fractured ends, and recurrent pain from muscular spasm 
avoided, and accurate approximation of the fragments accomplished 
without the necessity of resection with consequent shortening. Union 
will probably result by primary healing. If, however, the patient has 
not been seen for several days after the accident, or if the resulting 
shock or other circumstances prohibited immediate interference, the 
best results are probably accomplished by not operating until about the 
sixth or seventh day. This allows the circulation to be re-established, 
the infiltration to disappear, and the tissues to regain tone, so that the 
increased traumatism of the operation and possible infection may be 
readily combated by the forces of nature. In this way the risk of 
infection is reduced to a minimum. 

Class B. — Operations performed on fractures in which there has 
been failure to obtain and maintain accurate apposition by external 
mechanical appliances should depend upon several factors. In these 
fractures there are certain types in which is obtained a fair functional, 
but a poor anatomical result without operation. Examples are occa- 
sional oblique fractures of the tibia, fractures of the clavicle, of the 



90 TREATISE OX FRACTURES 

surgical neck of the humerus, of the shaft of the femur, of the shaft 
of the radius and ulna combined or separate. In these injuries opera- 
tion should be performed, when by repeated radiographic examination 





Fig. 55. — Flexion and abduction of the thigh in subtrochanteric fractures of the femur with or without 
counter-pressure on the upper fragment. Useful in applying gypsum case or reducing fragments. 

it is shown that the anatomical adjustment of the fragments is so 
poor that bad functional results with possible incapacity for work are 
bound to follow. 

Class C. — In non-union, deficient union, or faulty uriion the time of 
operation is dependent upon several factors. The patient's general 



OPERATIVE TREATMENT OF CLOSED FRACTURES 91 

health should be improved and local efforts made to promote union in 
cases of non-union or deficient union. Very often sufficient time has 
not been allowed for firm union to be complete. Delay in firm union 
may be due to some general disease ; in such cases the condition should 
be corrected. After all efforts have failed, operation should be per- 
formed. In fault}- union operation may be performed any time, al- 
though it is advisable not to delay too long on account of the secondary 
shortening of the muscles and the readjustment of neighboring joints 
and bones to the new lines of support which gradually develop. 

Surgical tables are a good form of traction apparatus to reduce 
the fracture, and maintain immobilization during operation and while 
the external gypsum case is being applied. They are expensive and 
only available in hospitals, as a rule. Compound pulleys or manual 
traction and counter traction will usuallv suffice. 




Technic of Operation in Closed Fractures. — There are many 
methods of procedure in use for the reduction and anatomic approxima- 
tion of fragments. The technic of exposing the fractured ends of the 
bones is practically the same no matter what form of internal fixation 
is used. The technic may de divided into the following stages : 
preparatory treatment ; reduction and approximation without internal 
fixation ; reduction and approximation with internal fixation. 

The preparatory treatment consists in a thorough general physical 
examination to detect, and the adoption of means to cure or modify, 
any pulmonic, cardiac, arteriosclerotic, or renal lesions, and the giving 
of a cleansing enema, if an early operation is determined upon. When 
the time has been selected, the patient should be given a cathartic. The 
local treatment consists in shaving the entire extremity, or the region 
of the fracture, followed by a thorough cleansing of the part with 
green soap, sterile water, and 70 per cent, alcohol the day before opera- 
tion ; the day of operation cleansing with benzine and painting with 
tincture of iodine. 



12 



TREATISE OX FRACTURES 



The operation should be performed under general anaesthesia. The 
use of the tourniquet or Esmarch bandage is not advisable, though its 
advantages might be considerable during the operation by giving a 
bloodless field. The post-operative bleeding usual after its use is un- 
desirable, and is liable to promote wound infection. A large incision 
should be used and all bleeding controlled as it arises. The incision 




-Support and traction of the left arm with counter-traction bv a wide sling around the 
body. This position is used for operations on the humerus. Hawley table. 



' 




plate during operative fixation of old femoral fracture. 



should he sufficiently large to permit thorough inspection of the fract- 
ured ends and protrusion of the fragments if deemed necessary. A 
line of approach t<> the -eat of fracture should be selected which will 
not injure important structures. The muscles should be separated in 
their intermuscular plane-, when possible, and if not. in a direction 
parallel to the course of their tihre>: nerves and blood-vessels should 
•■•fully avoided. The periosteum should not be stripped away 
from the hone, if it can he averted, and loose fragments generally 



OPERATIVE TREATMENT OF CLOSED FRACTURES 



93 




should not be removed; all bleeding should be controlled, and blood 
clots removed by gauze sponges ; intervening structures should be care- 
fully disengaged from the rough ends of fragments and 
placed in their normal relations, torn structures should be 
sutured with catgut, if deemed necessary. 

Repair Without Internal Fixation. — It may be 
found feasible after reduction to maintain approxima- 
tion without any means of internal fixation. Such cases 
are very few unless there is marked separation of the 
fractured ends or a parallel bone for partial support. 
If the operation is performed shortly after injur}-, 
it may then be found possible, by moderate manipula- 
tion, or by angulation of the fragments out of the 
wound, to bring the fractured ends in apposition and 
lock them together without the use of additional means 
of support. Great care must be taken, however, to 
maintain the corrected position of the parts until the 
external splint is applied. 

Repair with Internal Fixation. — While, in a 
considerable number of operative cases, entirely satis- 
factory retention may be maintained without the use of 
internal means of fixation, the majority of cases re- 



quire 



it. Various mechanical appliances for fixation ation 




have been used for holding the fragments in apposition. umopposite^LTes" 




Fig. 60. — Low fracture of surgical neck of right humerus. Upper end of lower fragment is pulled 
upward by deltoid muscle. 

Fig.6i. — Application of Lane plate in low fracture of surgical neck of right humerus. (See Fig. 60.) 

They may be divided into six classes : absorbable suture, Straus catgut 
mat; fascial tubes; non-absorbable sutures, as thread, silver and 



94 



TREATISE ON FRACTURES 




\ 



Fig. 64. Fig. 65. 

ondyle of humerus. Fig. 63. Anteroposterior view 
Hon upward of olecranon of ulna. Fig. 65. Lateral 
•.- fair approximation of fragments by Sherman screw and wire loop. Screw 
has brok ray good. Sere.-. 

other kinds of wire (Fig. 59); bone or metallic ferrules, ivory, 
bone or metallic plugs and pin-, and ivory, bone or metallic nails 
ami screws; the circumferential use of wire; clamps extending from 



96 



TREATISE OX FRACTURES 



the outside to the fragments like those devised by Parkhill; specially 
designed plates and screws. 

The plates of Lane and of Sherman are probably most frequently 
used for fixation in nearly all varieties of fracture calling for opera- 
tive treatment (Fig. jt>)- Exceptions are fractures of the olecranon 
and patella, where probably the best results are obtained by either 
absorbable or non-absorbable sutures applied to the tendinous ex- 
pansions and ligaments near the seat of fracture; certain forms of 
articular fracture in which the best means of approximation are specially 




71 AND 72. 



-Result obtained by operation in case of fracture of 



shafts of radius and ulr 



designed screws or nails, like those designed by Lambotte, Codivilla 
and Roberts, answer well. 

The technic perfected by Lane should be carefully followed in 
the mam rhe parts should be thoroughly prepared. A large free 
■ncis.on should be made with care, to avoid important nerves and ves- 
Stenle cloths are placed over the parts and attached to the edges 
;» the wound by clips. This precaution is taken to prevent introduc- 
fton o« organisms from the skin into the wound. Bleeding is thor- 
oughly controlled by the use of long-handled forceps of sufficient 



OPERATIVE TREATMENT OF CLOSED FRACTURES 97 

strength to thoroughly occlude the blood-vessels without the necessity 
of a ligature. All instruments used by Lane have long handles so that 
the operator's hands shall not be placed in the wound. Manipulations 
of the bones are carried on by means of levers and clamps. After the 
ends of the bone have been freely exposed, the wound is enlarged suffi- 
ciently to expose the entire length of the fracture and allow of a suffi- 
ciently long plate to be applied to secure immobilization of the frag- 
ments. Very little force is necessary to bring the fragments into 
apposition. The ends of the fragments are seized near the seat of 
fracture with powerful forceps or clamps, and by means of traction 
or by protruding the fragments through the wound the ends may be 
coapted or locked. During the attempts at replacing the fragments, 
traction and counter-traction may be made by an assistant or by a 




FULL SIZE 

Fig. 73ft. ■ — Lane's bone holding forceps, 



th serrated jaw. 



Fig. 73c. — Lane's bone plate. 

specially adapted mechanical apparatus. The fragments should be 
brought to their normal position, and normal alignment of the bone 
should be obtained before the plate is applied. An improper fixation 
of the plate is often the cause of poor position of the fragments, sepa- 
ration of screws, fracture of the plate, and infection. On no account 
should the plate be applied until the fragments occupy the same relative 
position that they did before the fracture occurred. The plate should 
be held to the bone by a special clamp and one of the screw holes made 
and the screw introduced. A mistake commonly made is in the use of 
too short a plate or in making screw holes too large in diameter. It is 
not usually necessary to suture the soft parts about the seat of frac- 
ture. Lane advises suturing the fascia lata in fracture of the femur. 
The skin wound may be closed with any form of suture or with Michel's 
skin clamps. Whenever possible, plates should be well covered with 
7 




Fig. 74. — Subtrochanteric fracture of left femur. Impossible to maintain reduction of fragments 
by non-operative measures. Shows application of Lane plate, perfect anatomical apposition of frag- 
ments and fairly firm union six weeks after operation. Functional result perfect. 




i 11 plati 
".v holder and screw driver. 
-Sherman's metal-workers tap : . 



OPERATIVE TREATMENT OF CLOSED FRACTURES 99 



§.og 

s 2 IT 2 







^ 



100 



TREATISE ON FRACTURES 






les and should not be superficially placed. The parts should be 
held securely and carefully until some form of external dressing is 
applied. The best method of external dressing is a plaster-of-Paris 

ement which should be split down each side immediately after 




Fig. So. — Oblique fracture of shaft of left femur; moderate overlapping of fragments. 
Fig. 8i. — Oblique fracture of shaft of left femur; application of Sherman plate. 





Tf ^M 



Fig. 82. — Photograph taken at the end of 8 weeks after operation. Note absence of shorter 
and perfect alignment. 
Fig. 82a. — Frontview of same patient as shown in Fig. 82 taken at same time. 




Figs. 83 and 84. — Separation of lower epiphysis of femur. Difficulty in maintaining reduction of 
fracture. Apposition secured by means of silver-wire suture. 




la. Anatomical apposition of frag- 
*h shows result. Good function; 



imp* * ^ 





Pig. 89. Pig. 90. 

Figs. 87 and 88. — Comminuted fractures of tibia and fibula. Anteroposterior and lateral views. 
Pigs. 89 and 90. — Application of Lane plate and screws followed by moderate necrosis of ends of 
fragments (see Pigs. 87 and 88). 




\i) 92. — Lane plate and screws removed, beginning union. (See preceding figure;;.) 
Fig. 93. Fig. 94. 




ishorl aing, good function. (Sec preceding 





Fig. 97. Fig. 98. 

Figs. 95 and 96. — Oblique fractures of shafts of tibia and fibula. Over-riding of fragments and 
shortening. 

Figs. 97 and 98. — Application of Lane plate and screws to tibia. Perfect anatomical apposition of 
fragments of tibia. (See Figs- 95 and 96. ) 



106 



TREATISE ON FRACTURES 



application, so that the wound may be inspected, if necessary, and 
massage and passive motion given. 

Operations which are performed on account of failure to obtain 
and maintain accurate apposition by means of external mechanical ap- 
pliances are now to be considered. Failure to obtain and maintain 
accurate apposition of the fragments may be due to interposition of 
soft parts, to the nature of the fracture itself, to muscular action, or to 
faulty methods of immobilization. These cases are best treated by a 
primary period of extension for several days in order to overcome the 
muscular contraction. Tbe only difficulty in operations of this class is 
that of proper approximation without resection of the ends of the frag- 
ments. This, however, may be overcome by manipulation of the frag- 





Figs. 99 and ioo. — Final result in fracture of tibia and fibula after application of Lane plate and screws 
Xo shortening, perfect anatomical and functional results. (See preceding figures.) 

ments or by angulating them out of the wound and after locking 
them forcing them into the wound while extension is made. The ends 
of the fragments should be carefully freed of portions of muscular tis- 
sue, granulations, and callus. The technic otherwise does not vary 
from that of operations performed immediately after the injury. 

Those cases in which operation is performed for non-union, or 
faulty union, are more difficult to treat on account of the presence of 
secondary shortening and over-riding of the fragments, muscular con- 
tractures, the greater time required for the operation, and the neces- 
sity of reconstructive procedure on the ends of the fragments. Martin 
has shown that there is a rapid and at times a faint fall of blood-pres- 
sure with resulting shock from traction alone. This is particularly so 



OPERATIVE TREATMENT OF CLOSED FRACTURES 107 

in operations for delayed or faulty union of the femur in which traction 
is necessary. Careful observation of the pulse and hlood-pressure 
should he made in these cases, while forcible traction is being used. 

Constitutional diseases play but a small part in the prevention of 
union. Examination in such a condition not infrequently shows the 
fractured ends to be separated and the intervening space filled by 
muscles or fibrous tissue. The ends of the bone generally over-ride 
and are smooth, and a condition of pseudo-arthrosis may be present. 
The technic of operation varies somewhat from that used in recent 





Figs, ioi and 



-Open oblique fractures of tibia and fibula. Fireman had leg caught in truck. 



fracture cases. An extensive armamentarium is necessary to properly 
operate, and the use of efficient tools is the chief means of lessening the 
resulting possible infection by providing for a short operation with 
little traumatism. Here again one should guard against shock from 
prolonged traction. The pulse and blood-pressure should be carefully 
watched. All fragments of callus, and all muscular, fascial and fibrous 
tissue should be removed from between the fragments. These objects 
may be the cause of failure of union, and their removal with proper 
fixation of the fragments will do much to ensure union. In old stand- 
ing cases of ununited fracture and mal-union (Figs, ioi-iio), it is 




*ig& 10? and 104. — R^ult obtained after reduction and immobilization in gypsum case. Note 
noderate deformity and posterior angulation at seat of fracture. Roentgenograms at end of six 
Fig';. 101 and 102.) 





' 



>d anatomical and perfect 



OPERATIVE TREATMENT OF CLOSED FRACTURES 109 

necessary to resect the end of the fragments beyond the sclerosed area 
until the bone-marrow may be seen. In some of these cases it is neces- 
sary to remove large masses of exuberant callus in order to approxi- 
mate the ends of the fragments. Plating is not always necessary. 
There is no doubt that the presence of a foreign body the size of a 
metal plate often retards osteogenesis, and in many cases in which 
plates are used the resulting delayed union is due to this fact. 

Of great importance in the operative treatment of fractures is the 
proper approximation and retention until some form of external splint- 
ing is applied. Change in the line of the distal fragments will often 





Figs. 107 and 108. —Closed fracture of shaft of the tibia, followed by an acute suppurative osteo- 
myelitis. Shaft of tibia removed. Upper portion of tibia has regenerated. Lower portion as shown 
between two arrows consists of half of first metatarsal bone used as a graft made by Dr. P. T. Stewart. 
No union between portions of new bone. 



produce such strain upon some of the screws as to pull them out entirely 
and in some cases to even fracture the plate. The vanadium plate and 
screws, devised by Sherman, overcome, to a considerable extent, these 
drawbacks to the use of plates. The best form of external splinting is 
a carefully applied casing of plaster-of-Paris. This should be cut 
down each side so that massage and passive motion may be instituted 
within ten days. At the end of a few weeks a patient with a fractured 
tibia or femur may be allowed up on crutches, if the external casing 
gives proper support, and weight-bearing on bone is prevented. 

Dr. F. H. Albee has had valuable results from the use of bone 



110 TREATISE ON FRACTURES 

grafts in the operative treatment of recent fractures in which reduction 
cannot he obtained without exposure of the ends of the fragments. He 
uses a long strip of bone cut from the patient's tibia, and inserts it in a 
groove cut in the ends of the fragments so as to act as an autogenous 
splint. He has devised special instruments for removing the transplant 
or graft from the normal tibia and for cutting the groove in the fract- 
ured bone, which make his procedure a rapid, neat, and satisfactory 







107 and 10R shov 
atrophy. 



ing shorteniip. deformity, and muscular 



one i Fig. i i i !. lie also has special instruments for cutting the bone 
graft into pei;- or dowels and for boring holes in the bone to be re- 
paired for the insertion of kangaroo tendon -utures or. in certain case-. 
the bone pegs. The parallel or twin saws, the drill-, and the instru- 
aking the nails or dowel- are driven by an electric current. 
The Mbre operation i- particularly valuable in ununited fractures. l>e- 
il not only bold- tin- resected end- of the fragments in correct 



OPERATIVE TREATMENT OF CLOSED FRACTURES 111 

alignment, but furnishes osteogenetic cells which aid greatly in the 
development of ossific union. His method may be used without his 
complicated and extensive tools, but their use lessens the time of opera- 
tion and makes the result a neater looking one. Chisels, ordinary 
drills, osteotomes, and saws of various kinds will accomplish the same 
result in the hands of any surgeon with usual manipulative skill. 

The inlay graft (Fig. 112), as he calls it, is inserted after the 
fracture has been exposed by a free incision and the ends of the frag- 
ments cleared from surrounding soft parts. Excision of the ends, if 
necessary, otherwise simple manipulation with moulding, is used to 
overcome deformity. When the freshened ends of an ununited frac- 





Figs. ma and 1 1 16. (a) Albee's electric twin saw used in removing transplant from tibia and for 
cutting groove in the fractured bone, (b) Albee dowel cutter. 

ture or the bare ends of a recent fracture are in proper apposition, 
a gutter is made with the twin saws one-third to one-half inch in width. 
If the fracture is an ununited one, this gutter should run well beyond 
the sclerosed fracture ends. In. the tibia, for example, the parallel 
cuts should extend into one fragment for a distance of about five 
inches; into the other about two and a half inches. The strips of 
bone between the parallel saw cuts, which go down to the medullary 
canal, are removed by dividing the bone at the ends with a small 
osteotome or circular motor saw. The short strip is laid aside and 
the long one returned into the gutter so as to cross the break between 
the two fragments of bone, making a splice or inlaid splint. Placing 



112 



TREATISE ON FRACTURES 



the bony strip in this position leaves a short gap between the end of the- 
gutter and the end of the inlay in the fragment of bone from which the 
longer piece was taken. This unfilled portion of the channel is neces- 
sarily the exact length of the piece of bone which has been laid aside. 
This strip can be pushed into the gutter in order to reconstruct that 
portion. 

Such reposition is not necessary if the sur- 
geon thinks that he needs it to cut into nails or 
pegs for fastening other fragments of the same 
injury. The inlay is held in place by kangaroo 
tendon sutures, passed through holes drilled in 
the sides of the gutter and carried under the 
inlay and the ends tied over the inlay so as to 
force it down and hold it deeply in contact with 
the floor of the gutter. Four or five of these 
sutures are sufficient. Small chips of bone, taken 
from resected ends or from clean fragments re- 
moved in preparing the ends for operation, are 
distributed about the seat of fracture if there 
are vacancies to be filled by new bone. 

When an old ununited fracture is to be treated 
by the inlay method, the graft is taken from a 
healthy tibia of the patient. The width and 
length should be similar to the one cut out of a 
recent fracture to fix the same. Live bone pegs, 
or bone dowels, may be made from pieces taken 
in a similar manner. The inlay graft has for its 
only function the maintenance of apposition and 
alignment, and it should not be expected to 
take the place of external support necessary to 
prevent accidental displacement from muscular 
■ Yemeni or the handling of the patient by nurses. A gypsum dress- 
ing is applied after the soft parts have been sutured without drainage 
and appropriately dressed. Instead of using grafts with parallel sides 
cut with twin saws. Dr. Albee thinks that in some cases, particularly in 
fresh fractures, it is preferable to use a single saw and cut the trans- 
plant with converging sides going down to the marrow cavity. This 
i graft long and with wedge-shaped sides, cut down to the mar- 
row canal. In making pegs of live bone Dr. Albee prefers the cortical 
bone taken from the lower third of the tibia, because it is stronger. 
Such pegs or dowels can be used for fractures of the neck of the femur 
and. being living tissue, are probably much better than the ivory or 
dead hone dowels or pegs used by other surgeons years ago. Albee 
does not .are particularly in using bone grafts whether the periosteum 




Fig. 



-Al!..i\ 



sthod 



of inlay bone graft for fixation 
>f fractures. Graft has been 

Cttt from upper fragment and 

a groove cut into ] 

ment. The inlay graft is then 

placed in position as shown 
■d held in place either by 

bone pegs as shown in «i or by 
' ingaroo tendon su- 
■ '-•. n in b. 



Fig. 113. 







Figs, iis and 116.— Inlay bone graft in place in tibia. Note alignment of fragments with absence 
of deformity, except shortening. Single arrows point to site from which graft was taken and double 
arrows show two views the graft slipped down into place (see Figs. 113 and 114). (Courtesy of Dr. 
Morris Booth Miller and Dr. George G. Ross. Operated by Dr. Albee.) 
8 



114 TREATISE ON FRACTURES 

is removed or left attached to the graft. The value of living hone is 
much greater in these plastic reconstructions of hones than that of 
foreign materials. A centre of osteogenetic activity is provided by the 
insertion of the living bone from the patient's tissues. 

The time has probably arrived when the relative values of the 
bloodless and the blood-shedding routine treatment of fractures may 
be settled. Robert Jones, of Liverpool, was of the opinion a few years 
ago that simply improvement in the customary non-operative treat- 
ment of fractures would markedly increase its percentage of good 
results. Campiche, of San Francisco, has recently expressed his be- 
lief that bloodless surgery will probably, in competent hands, give 
excellent anatomical and functional cures in 90 per cent, of cases. 

The British Fracture Committee concluded, in 19 12, that a con- 
siderable proportion of failures of operative treatment arose from in- 
fection, a possibility even with the best technic, and that the operative 
method required special skill, experience and equipment; that although 
functional cure may he good with an indifferent anatomical result, the 
most certain way to obtain a good functional result is to secure a good 
anatomical curve; that no method not definitely promising a good 
anatomical result should be the chosen method of treatment; that the 
direct mortality of blood-shedding treatment was so small in com- 
petent hands as not to furnish a sufficient reason for its rejection, and 
that to insure its best result it should be adopted as soon after accident 
as possible. 

In 1913 the American Surgical Association Fracture Committee 
formulated these conclusions: That practitioners not trained in sur- 
gery as a specialty should adopt a routine non-operative method mid- 
way between prolonged immobilization on the one hand and the 
mobilization method of Lucas-Championniere or the traction method 
of Bardenheuer on the other; and that the watchwords for this class 
should be anaesthesia, plastic splints or traction, frequent inspection, 
frictions, early mobility, and delay in weight-hearing. That trained 
surgeons, restricted by moderate efficiency and facility, either personal 
or hospital, probably should adopt a routine of less prolonged im- 
mobilization than heretofore, or of traction with frictions, early light 
massage and mobilization for the usual run of fractures, and that they 
should restrict operative treatment to fractures known to be especially 
rebellious or found to be so ofter a few days' study. 

The Committee's answer to the question, What should be the rou- 
tine treatment for the skilled surgical expert with adequate facilities? 
was thai it makes little real difference in morbidity or mortality whether 
he adopts a bloodless or a blood-letting method for obtaining a func- 
tional and an anatomical cure, provided that he personally dominates 
the situation ,-|. to reduction, fixation and after-treatment, and sets the 



OPERATIVE TREATMENT OF CLOSED FRACTURES 115 

time at which the patient shall resume his original occupation, and 
provided he abandons the prolonged immobilization and accompanying 
negligence so customary in recent years on the part of many having 
the care of fracture cases in hospital wards. 

The American Surgical Association's Fracture Committee reported 
in June, 191 5, that its belief: that in non-operative management of 
fractures there is no method or splint universally applicable nor has 
any given splint or apparatus proved its superiority ; that traction 
methods are most frequently unskillfully employed, and with too little 
weight, as a rule, used, that counter traction is generally required, and 
that the gauge of the proper' weight is the amount necessary to over- 
come the shortening ; that plaster encasements and moulded splints are 
especially useful after the fracture has been satisfactorily reduced; 
that fractures should be reduced immediately after injury if it is pos- 
sible to obtain and apply at that time proper retaining appliances ; that 
anaesthesia should be employed, as a rule, to facilitate reduction and 
prevent pain ; that neither the non-operative nor the operative method 
is to be recommended exclusively; that the operative method, when 
adopted, should be employed early, and should, for closed fractures, 
be undertaken only by experienced surgeons thoroughly equipped by 
training and with proper instruments and apparatus. 



CHAPTER III 

FRACTURES OF THE CRANIUM 

General Considerations. — In many fractures of the skull the frac- 
ture is of secondary importance and the treatment is directed more to 
improvement of the associated injury of the cranial contents than to 
the fracture itself. Fractures of the skull may be entirely limited to 
the locality of the fracturing force without any injury to the cranial 
contents. On the other hand there may be fractures in which there is 
little if any injury at the site of the fracturing force, but there may be 
extensive damage done to the brain and its membra:. 

The contents of the three fossa? at the base of the brain may be 
enumerated as foil 

Anterior cerebral fossa: frontal lobes: olfactory ner - 

Middle cerebral fossa : temporosphenoidal lobes : cavernous 
sinuses; internal carotid arteries: optic nerves: motor oculi nerves; 
trochlear nerves : trigeminal nerves : abducent nerves. 

Posterior cerebral fossa : cerebellum : occipital lobes : lateral 
sinuses; seventh, eighth, ninth, tenth, eleventh and twelfth nerves. 

Skull — Anatomy. — The skull is the bony covering of the brain 
and the container of the mouth and the organs of hearing, seeing, and 
smelling. It is divided into the bones of the cranium and the bones of 
the face (Tig. 117}. The cranial bones are the frontal, the parietal. 
the temporal, the occipital, the sphenoid, and the ethmoid. The bones 
of the face are two superior maxilla, two malar, two nasal, two palate, 
two lachrymal, two inferior turbinated, one vomer, and one inferior 
maxilla. 

The cranium encloses the brain, membranes, and bio 
may be divided into the vault and the base. 

The principal landmarks of the skull (Fig may be briefly 

enumerated: Sutures: Frontal suture, between the two frontal bones, 

-ated early in life: sagittal suture, separating the two parietal 

are. separating the parietal and the frontal bones: 

the lambdoid suture, separating the parietal and the occipital bones. 

The glabella, the flat surface above the root of the nose: the bregma, 

nal and sagittal sutures which is the p 
of the anterior fontanelle in infancy. The lambda is the junction of 
rabdoid sir ,,f t j le „,-,.. 

vile in infancy. The pterion. the junction of the anterior to- 
tal, the frontal, the temporal and the greater 
• one and a halAnches 
behind the external angular process of the frontal bone and about the 



FRACTURES OF THE CRANIUM 



117 



same distance above the zygoma. The inion, or external occipital pro- 
tuberance, may be palpated in the median line posteriorly at the junc- 
tion of the head and neck. This point marks the position of the torcu- 
lar Herophili, or the junction of the superior longitudinal, the straight, 
the occipital, and the two lateral sinuses. 

The course of the frontal and sagittal sutures corresponds to a line 
drawn from the root of the nose (glabella) backwards in the median 
line to the external occipital protuberance (inion), and marks the posi- 
tion of the superior longitudinal sinus and the longitudinal fissure of 
the cerebrum. 

The mastoid process can be readily palpated behind the ear. About 




Great w i'iil,' of sphenoid 



Superior maxillar 
Infra-orbital foran 



I septum 



Mental foramen 



Fig. 117. — Front view of skull (Piersol). 

half an inch above and three-quarters of an inch posterior to the tip of 
the mastoid process is the junction of the lambdoid and squamous 
sutures, the asterion. The position of the horizontal portion of the 
lateral sinus is represented by a line drawn from the external occipital 
protuberance to a point one inch above the external auditory meatus. 
The course of the sigmoid of the lateral sinus may be represented by a 
line drawn from the termination of the horizontal portion of the lateral 
sinus to the top of the mastoid process. The middle meningeal artery, 
a branch of the internal maxillary artery, enters the cranial cavity 
through the foramen spinosum. It occupies the groove in the greater 
wing of the sphenoid bone and divides into the anterior and the pos- 
terior branches. The anterior branch crosses the great wing of the 



118 



TREATISE OX FRACTURES 



sphenoid and enters the groove in the anterior inferior angle of the 
parietal bone. During a part of its course this groove is converted 
into a canal. The anterior branch continues through this canal, runs 
upward near and parallel to the coronal suture towards the longitudinal 
sinus, and it at times is accompanied by the sphenoparietal sinus in a 
part of its course. The smaller posterior branch crosses the squamous 
portion of the temporal bone and continues along the line of junction 
of the squamous and petrous portions of the temporal bone to the pos- 
terior inferior angle of the parietal bone, to divide into its final 
branches. On account of its position in the groove of the great wing 
of the sphenoid and also in the groove and canal of the parietal bone 

Bregma 



Stephanion 
Inferior stephanion 




Gonloa 

Pic. I i 8. — Lateral view of skull (Piersol). 

and its course through the foramen spinosum, it readily can be seen 
how fractures in this region may open the vessel, either from altera- 
tion in the shape of the canal or foramen or by spicules of bone piercing 
its coats. The large hemorrhages external to the dura occasionally 
found in Mich arterial lacerations are accounted for by the looseness 
with which the dura is attached to the cranium at this position. Mosl 
of the cerebral symptoms seen in fracture in this position are motor in 
character, because the intracranial bleeding from a torn middle men- 
ingeal artery compi , brain in its motor area. 

The principal fissures of the cerebrum are the longitudinal, the 
sylvian, the Rolandic and the parieto-occipital. 



FRACTURES OF THE CRANIUM 



119 



The nasion or the nasofrontal suture, and the temporal ridge mark- 
ing the upper attachment of the temporal fascia and muscle, are topo- 
graphical points of the cranium easily located (Figs. 119a and b) . 
The external angular process is the outer extremity of the frontal 
bone where it articulates with the malar bone. The stephanion is the 
point where the temporal ridge crosses the coronal suture. 

The lower level of the brain may be approximately determined by 
a line drawn horizontally across the frontal region through the upper 
part of the glabella. This line should be continued from the external 
angular process of the frontal bone through the preauricular fossa to 
the external occipital protuberance. The cerebellum will be found be- 
tween the latter portion of this line and a line drawn from the mastoid 
process to the inion. 





Fig. 119, a and b. — Craniocerebral localization: l-l', Reid's base line; 2-2', supra-orbital line ; 
3, middle meningeal artery; 4, anterior branch; 5, the sites for trephining for the anterior branch; 6, the 
posterior branch; 7, the site for trephining for the posterior branch; 8, the lateral sinus; 9, the inion; 
10, the mastoid process; 11, the facial nerve; 12, the temporal crests; 13, the temporal fossa. (Modified 
after Rawling.) 

The base of the cranium (Fig. 120) may be divided into three 
fossae : the anterior, the middle, and the posterior. In fracture of the 
base involving the anterior fossa, blood may enter the orbit and produce 
a subconjunctival ecchymosis, or in conjunction with cerebrospinal 
fluid it may escape from the anterior nares or posterior nares. The 
blood-producing subconjunctival ecchymosis may come from rupture 
of the meningeal vessels, the ophthalmic artery or vein, or the outer 
anterior or posterior ethmoid vessels. Bleeding from the nose may be 
indication of rupture of the nasal vessels. Hemorrhage may also 
occur in the nose through rupture of the meningeal vessels in fracture 
of the cribriform plate of the ethmoid. Hemorrhage about the eyelids 
and subcutaneous tissue of the orbit may be the result of a blow from 
the outside and not as result of fracture of the cranium. In fracture 



] 20 



TREATISE OX FRACTURED 



of the middle cerebral fossa blood and cerebrospinal fluid may escape 
from the ear. For this to occur there must be a laceration of the 
arachnoid, dura mater, mucous membrane of the wall of the tympanuin. 
and the tympanic membrane, in addition to fracture of the base of the 
skull. Fracture of the middle fossa may involve the sphenoid or basilar 
'ie occipital bone and produce bleeding into the mouth. It 
may also cause an accumulation of blood posterior to the pharynx. In 
fractures involving the posterior cerebral fossa bleeding may show in 
the posterior triangle of the neck. 

The crar. in density and rigidity in different parts and in 







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different individuals. In speaking of fractures of the " cranium."' the 

ften used rather inaccurately for cranium. This use 

mmon that it has been employed in these pages quite frequently. 

The cranium derives its rigidity and strength from its shape, the thick- 

rmation. and from the presence of 
thickened bone in certain places, which forms buttresses running from 
the base t.» the vault. The vault of the skull is strong, not only on 
accoir pe, but also on account of the presence of the two 

ed by diploic tissue. The diploe is most abundant in the 
frontal, parietal, and upper occipital regions. These regions are un- 
usually strong in contrast with the squamotemporal and cerebellar 
hich there is very little diploic tissue. In the base certain 



FRACTURES OF THE CRANIUM 121 

areas are strengthened by buttress-like thickenings, which extend up- 
wards from the crista galli, from the external angular process, from 
the auditory region, and from the occipital protuberance. Parts in- 
tervening between these buttresses are the weak areas at the base. 
The elasticity of the skull may be demonstrated by letting it fall upon 
the floor; it does not immediately remain at rest like an unelastic body, 
but makes several bounds like a baseball or an ivory sphere. 

Frequency of Fractures of the Skull. — From a study of 8560 fract- 
ures von Bruns found 292, or 3.4 per cent., fractures of the skull. 
Chudowsky, from a study of 2366 cases of fractures from the surgical 
clinic of Buda-Pesth, found 90, or 3.8 per cent., cases of fracture of the 
cranium; 52.2 per cent, were fractures of the vault of the cranium, and 
47.7 per cent, were fractures of the base. The fractures of the vault 
were closed in 32.6 per cent, and open in 67.3 per cent. The site of 
the fractures were as follows : frontal region, 44 per cent. ; parietal 
region, 40 per cent. ; temporal region, 40 per cent. ; and occipital region, 
2 per cent. The etiology of the fractures was as follows : by falls, 50 
per cent. ; by blows or kicks, 35 per cent. ; by being run over, 9.2 per 
cent. Sixty per cent, of the fractures occurred between the ages of 
twenty and forty years, and nine times more frequently in men than 
in women. H. Plagemann has compiled the statistics of fractures from 
the Rostock clinic as follows: In 11 06 cases there were 31 cases of 
fracture of the skull, or 2.8 per cent. ; in 1 165 cases there were 34 cases 
of fracture of the skull, or 3.07 per cent. ; and in 1393 cases there were 
59 cases of fracture of the skull, or 4.23 per cent. Of these 59 cases 
there were 3 between one and ten years ; 1 1 between eleven and twenty 
years; 16 between twenty-one and thirty years; 11 between thirty-one 
and forty years ; 6 between forty-one and fifty years ; 6 between fifty- 
one and sixty years ; 6 between sixty-one and seventy years. 

Etiology. — Fractures of the cranium are the result of direct or 
indirect violence acting upon the skull ; and the resulting lesion de- 
pends in a great measure upon the site to which the violence is applied, 
its character, and the method of injury. The lesion may consist, if 
only the vault of the skull is involved, in a fracture of the outer table, 
of both the outer and the inner tables, or rarely of the inner table 
alone. About two-thirds of fractures of the vault are complicated by 
lines of fracture extending to the base of the skull. Fractures may be 
classified as fissures, comminuted, diastasis of sutures, depressed, per- 
forated, elevated, and gunshot. 

Fissured Fractures (Figs. 121, 122, 123, 124 and 125). — This 
variety is generally seen as a single line of fracture with very little if 
any inequality of the two edges of the bone forming the line of separa- 
tion. They are most commonly seen at the base of the skull and are 
the result of either bending or bursting forces. The fissure may in- 



122 



TREATISE ON FRACTURES 




n, transverse fracture of the vault. The fracture may be traced from the 
left temporal region through the parietals, crossing the sagittal suture close 
to the occipital bone into which the fracture passes behind the temporal bone. Patient fell upon 
sidewalk; symptoms of compression resulted and death occurred in 12 hours. A clot of blood dis- 
placed the dura mater under the parietal bones. (Mutter Museum, No. nsi-37.) 

Fig. 122. — Skull. Fracture of the base. In this instance there is evidence of a point in the frontal 
region where the blow was received; no fracture is, however, visible at this situation. The occipital 
bone is seen to be fractured into three fragments; the line of fracture diverges from a point immediately 
below the superior curved line 2 cm. to the right of the ligamentum nucha;; from this point one line 
passes upward to the superior angle of the bone, another obliquely, toward the left mastoid process, 
the third nearly to the right styloid process. (Mutter Museum, No. 1 151.03.) 




_ f. ! mum; fracture of the right temporal and parietal bones. Recent. 

■ fractun border ol th< squamous portion of the righl temporal bone 

illy backward th. . . ,„, „,,, ,., ,i,, ,,.,),, ,,,,,, ,,,, ,,, ,i ,„,.,, |„ 1II( „„. ir 



volve several bones, and the split may run in a straight line irrespective 
of the direction of sutures. While the fissure generally occurs as a 
single crack, it may be forked or have a multiple character. Some- 




Fig. 124. — Rontgenogram showing fissured fracture of cranium. Line of fracture extends antero- 
posteriorly in vault with supplementary lines extending into posterior fossa at base. Child one year of 
age, fell from the arms of grandfather while being carried. 





Fig. 126. — Comminuted fracture of skull, frontal region. 
Fig. 128. 




I 1 ■ ■ 

ral. On the right side the greater 
ier wing through the median line, and the 
.. then the fracture passes just a- 

rper border of the temporal bone. 



FRACTURES OF THE CRANIUM 



125 



times it is impossible to recognize a fissured fracture during life on 
account of the symmetry of its edges. At times if the fracture is com- 
pound portions of hair or clothing may be caught and held between its 
edges. It is doubtful whether a fissured fracture may be detected by 
percussion alone or combined with auscultation. Fissured fractures 
may occur alone or in combination with depressed or gunshot fractures 
of the skull. 

Comminuted fractures (Figs. 126-132) are usually the result of 
direct violence applied over a small area, and occur most frequently 
in the vault of the skull. The)- are characteristic of fractures by bend- 
ing. They may involve a very small area or be distributed over "a large 
surface. The fragmentation may consist of two or many pieces. 



Fig. 130 




Fics. 129 and 130. — Calvaria. Fracture of the right parietal bone. The line of fracture extends 
upward from the base to the vault, involving the right parietal and a portion of the left parietal. This 
shows well how the line of fracture is not affected by the sutures. (Mutter Museum. Brinton Collection.) 



Fractures by diastasis (Fig. 133) are a modification of a fissure 
or comminuted fracture, in which the line of separation is deflected 
along that of a suture. Necessarily it is seen during early or adolescent 
life, before the adjacent bones forming suture lines have ankylosed. 
In later life the condition cannot be truly described as a diastasis, be- 
cause the sutures have ossified. Lines of fracture, however, may occur 
along these ossified sutures in conjunction with fissured or comminuted 
fractures. 

Depressed Fractures (Figs. 134-137). — There are three varieties 
of uncomplicated depressed fracture : Fractures involving the outer 
table alone, the so-called pond and gutter fractures, and fractures in- 
volving both tables of the skull. These varieties of depressed fracture 
are the result of direct violence applied to the vault of the skull over a 



- 



TREATISE ON FRACTURES 





FRACTURES OF THE CRANIUM 127 

small area, and are usually due to blows with a heavy instrument like 
a hammer or by the impact of an object falling from a height. 

Fractures involving only the inner table of the cranium occur also. 
These are produced by a circumscribed blow applied to an elastic skull, 
when the force applied is not great enough to produce depression of 
both tables. This form of fracture is very rare. Depressed fractures 
have peripheral depressions, when one portion of the fragment that is 
driven in is attached to the intact bone, and the other slopes toward the 
centre of the depressed area and central depressions when the entire 
depressed fragment is below the level of the intact bone. 

Perforated fractures (Figs. 138 and 139) are the result of blows 
upon either the vault or base of the skull with a blunt instrument, or 
with a sharp weapon, such as tools, bayonet, and hatchet, applied with 
sufficient force to penetrate the skull. As a rule all perforating fract- 
ures are associated with depression, comminution of fragments, and 
severe cranial injury. Fragments of bone may be driven deeply into 
the brain. Perforating fractures obviously are open fractures. Gun- 
shot fractures are usually perforating fractures. 

Elevated fractures of the cranium are rare and are seen mainly in 
military life. They result generally from sabre cuts, and may involve 
either the outer table alone or both tables together. 

Gunshot fractures are a variety of perforating fractures, but they 
deserve some special consideration. The form of fracture and the 
extent of injury to the intracranial organs due to the missile depend 
upon several factors. The lesion produced is dependent upon the 
nature, size, and velocity of the bullet, the angle of impact, and par- 
ticularly upon the distance from which the bullet is fired. Von Berg- 
mann states that with the modern, hard shell, high velocity bullet at 
short range the skull cap, together with the scalp covering it, is torn 
off ; at a range of 50 metres 
there is a wound of entrance 
and one of exit, the scalp is 
preserved, and the skull held 
together, although the latter 
was broken into many frag- 
ments. At 100 metres there 
is less destruction of the skull ; 
and the lines of fracture are 
arranged radially, in part en- 
circling the bullet holes like a 
bending and bursting fracture. 
The diameter of the wound 
of exit is about 20-30 mm. PlG . I33 ._ Skull . fracture of the superior angle of the 

4t Ron fn nnn Tnf»tt-pc flip occipital bone with fracture of both temporal bones in 
T\l OOO tO 1200 metres tne horizontal line separating the squamous from the mastoid 

fissurin°' encircling" the bullet p° r V? nsand R assingthroughtheauditor y' canals - (Mat- 





Fig. 134- — Rontgenogram showing depressed comminuted fracture of skull, parietal region. 
Fig. 135a Fig. 1356 




PtO. 1 IS 'i .ii.d b 



inutcd, and depressed. 



The injury was from a slit | [mmediately above the temporal bone. 1 here are no radiat 

' 1 Hi. painial immediately over the temporal bone: 

• .'.I. I .. 1. 1. ...... y ■.,.,:. |„,l ,,l unmcdiately. 

two (Mutter Museum No 115135) 



Fig. 136. 



Fig. 137 




Fig. 136. — Calvarium. Depression of the right parietal. In the posterior portion of the 
right parietal there is a circular depression having a diameter of from 4 to 5 cm. and a depth of 7 cm. 
A corresponding depression is seen on the inner side. Evidence of fracture is seen. (Mutter Museum, 
No. 1151.14-) 

Fig. 137. — Calvarium; depressed fracture of the left parietal bone 5-5 cm. long in the left parietal 
bone parallel to the interparietal suture. The fracture was probably made by a single blow of a a sharp 
instrument. Both tables involved. (Mutter Museum, No. 1151. 11.) 




Fig. 138. — Anterior half of calvarium. Punctured fracture at three points with depression of 
the internal table. Boy, 16 years, fell upon a large wheel covered with spikes of polished iron 9 cm. 
long sharp at the points and 6 mm. at the base. It was practically a revolving comb for disentangling 
hemp. The boy was impaled on the hooks and it required two men to release him. Symptoms of menin- 
gitis and later tetanus developed and boy died at end of ten days. (Mutter Museum, No. 1151.10.) 

Fig. 139. — Calvarium; fracture of left frontal and both parietals. Recent. The fracture evidently 
was made by a saw. There is an opening 13 cm. long of irregular shape situated in the left frontal 
and parietal bones. (Mutter Museum, No. 1151.09.) 

9 



130 



TREATISE ON FRACTURES 



holes disappears, and only radial fissures are present. At 1600 metres 
these latter disappear, except that there is one fissure connecting the 
wound of entrance with the wound of exit. This latter disappears at 
1800 to 2400 metres, and the wounds of entrance and exit are clean- 
cut bullet holes. At 2700 metres the skull is not perforated, the bullet 
remaining in the brain. The above experiments were made with a hard 
lead, steel, mantled bullet, fired from a small calibre arm and had an 
initial velocity of 2000 feet per second. The lesions of the bone are 
complicated by and intensified by that of the brain itself. It has been 
shown by v. Coler that there is an explosive action upon the brain pro- 
portionate to the distance from which the bullet is fired. These changes 




Fir.. 140. — nia(jrammatir illustration showing effects of a perforating bullet wound of skull and brain 
(Motlified after R.-iwling.) 

range from total removal of the brain from the shattered skull in short 
distances to simple perforations at long distances, and finally to simple 
concussion when the bullet does not penetrate the skull at all. The 
results produced by the pistol bullet at short range are more or less 
similar to those produced by the modern high velocity bullet fired from 
a ritle al long range, according to v. Bruns. Depending upon the angle 
of impact, there may be perforated, gutter, and depressed fractures of 
varying degrees. 

The wound of the skull is more or less dependent upon the size and 
shape of the bullet. The composition of the bullet and the fact of it 
having a hard steel jacket or not will greatly influence the resultant 
bone lesion. Bullets having a soft nose, the so-called dum-dum bullet, 
have an explosive action. 



FRACTURES OF THE CRANIUM 



131 



The wound of entrance shows changes in the internal table similar 
to that of the external table at the point of exit, influenced, of course, 
by the projectile having passed through the brain. The bullet may 
have somersaulted, and the wound of exit may be made by the blunt 
rear end of the bullet. Ordinarily the wound of exit has the edges 
everted, portions of bone may be found in the scalp, and the wound is 
larger than that of entrance (Fig. 140). 




Fig. 141. — Gunshot wounds of head with fractures of skull. Shows two wounds of entrance. 
First is close range with powder marks surrounding it ; second, close range with actual contact and exten- 
sive gas wound which has caused two extensive rips in the skin. (Courtesy of Dr. Wm. S. Wadsworth.) 

Fig. 142. — Shows the base of the brain case with two probes indicating direction of bullets. 
One passed into middle fossa, caused a number of lines of fracture in anterior and middle fossa indi- 
cated by marks. The other passed backward, caused extensive bleeding, and caused a general group of 
fractures in the left occipital region. (Courtesy of Dr. Wm. S. Wadsworth.) 



Of utmost importance in gunshot fractures of the skull is the injury 
to the brain (Figs. 141 and 142). These changes vary from a single 
track, with points of entrance and exit, with extravasation in neighbor- 
ing areas, to a condition in which the brain resembles a hemorrhagic 
pulp. The latter condition is the result of close range bullet wounds, 
in which the disintegrating and pulpefying of the brain is produced by 
the expansile effect of the bullet and is accompanied by hemorrhage 



132 TREATISE ON FRACTURES 

into the ventricles and meninges. The condition is invariably fatal. 

Hans Brun, from a study of 470 cases of fracture of the skull dur- 
ing 20 years at the Cantonal Hospital in Zurich says that 60 per cent. 
are the result of falls from a height, about one-half involve the base 
often alone, and that 70 to 75 per cent, of fractures of the vault are 
accompanied by fractures of the base. Fractures of the vault are, 
according to this writer, more often open than closed and occur with 
equal frequency in the frontal, parietal, and temporal regions, being 
rare in the occipital region. Fractures of the base are most common in 
the middle fossa. 

Fractures of the Vault of the Cranium. — Fractures of the vault 
of the skull may be the result of violence applied directly to the vault 
or may be due to the extension of a fracture of the base. Fractures of 
the vault are complicated by fractures of the base in about two-thirds 
of cases. Fractures of the vault are often open, and, when so, are 
more liable to limitation to the vault. Fractures of the vault depend 
upon the site of the application of the force, the direction of the force, 
and the degree of violence used. Most fractures of the vault are by 
direct violence, and those of the base by indirect violence. Exceptions 
to the latter are gunshot wounds of the base through the mouth or 
orbit. Fractures of the vault may be confused with hsematoma of the 
scalp, in which depression of the skull may be considered. Haematoma 
may be recognized by the disappearance of the ring on deep, firm pres- 
sure, the bluntness and smoothness of outline, by the fluctuation and 
softness of its centre, and by the minor degree of cerebral disturbance. 
1 f in doubt and there are symptoms of compression, the surgeon should 
treat haematoma as a depressed fracture. 

Fractures of the Base of the Cranium. — Fractures of the base of 
the skull are usually the result of indirect violence, applied from the 
vault and transmitted to the base; or of direct violence. Gunshot and 
other perforating wounds of the mouth or orbit, the driving upward 
of the condyles of the inferior maxilla against the socket by a blow 
upon the chin (Fig. 143) . a blow upon the nose, a fall upon the feet or 
buttocks with transmission of the force through the spinal column, 
may cause fracture of the base of the cranium in the anterior, middle, 
or posterior fossa. a< the case may be. 

Mechanism of Fractures at the Base.— The mechanism of fract- 
ures of the skull differs from that of all other fractures. This is due 
to a number of factors, the principal of these being the hollowness, 
shape, and elasl icily of the skull. Many theories have been given from 
time to time to account for the types, locations, and varieties of fract- 
ure- produced, especially in those involving the base of the skull, and 
physical laws have been deduced to account for the pet theories of 
each exponent. Many clinical and experimental investigations have 



FRACTURES OF THE CRANIUM 



133 



been carried on from time to time, directed toward a solving of the 
elementary principles of basal fractures. Notable investigations have 
been carried on by Teevan, Aran, von Wahl, Rauber, von Brans, von 
Bergmann, Rawling, Kocher, Messner, Hermann, and others. Of 
these the most important theories are as follows : 

Aran's theory of irradiation was that fractures of the base are 
due to extension from a fracture of the vault and that the lines of 
fracture follow the shortest anatomical route to the base. It presup- 
poses the co-existence of vault and basal fractures. The theory was 
modified after observations made by v. Brans upon the elastic properties 




Fig. 143. — Illustrates possibility o£ fracture of the base of the skull by transmitted force applied 
to the lower jaw through the condyle, on account of the thinness of the glenoid fossa (marked by arrow). 
The posterior part of the zygomatic process has been removed for clearness of demonstration. 



of the cranium. The conclusion was that these fractures are the result 
of changes in form, and that the lines of fracture occur along the line 
of least cohesive resistance toward the pole of impact. This theory 
has received the support of Messner, Hermann, and von Wahl. 

The Bursting Theory. — This is founded upon the elastic and 
cohesive properties of bone. Compression of one pole of the cranium 
toward the other produces a diminution in the diameter of the axis 
with bulging of the other diameters, most marked at a right angle to 
the line of pressure. When this bulging exceeds the normal elasticity 
and cohesiveness of bone, a fracture occurs, the line of fracture de- 
pending upon various factors. When the fracture occurs on a line 



134 TREATISE ON FRACTURES 

parallel to the line of the compressing force the cranium breaks along 
the convexity and a bursting fracture is produced: when the line of 
fracture is at right angles to the compressing force the lesion is termed 
a compression fracture. Rawling takes exception to these theories on 
the grounds that they are based upon experimental fractures produced 
by compressing the head of a cadaver in a tight-fitting box; that cases 
of bilateral compression .are of infrequent occurrence; and that the 
great majority of basal fractures are the result of blows applied directly 
at the level of the base or of violent forward propulsion of the body, 
the head coming in contact with the resisting object. The cranium, 
he contends, cannot be regarded as a sphere, because it forms only 
about two-thirds of a sphere, and does not possess requisite elasticity 
to account for fracture by this means. 

The coxtrecoup theories were first propounded by the French 
surgeons, and though one or other has been accepted by many, they 
are doubtless mechanically unsatisfactory explanations. One of the 
theories based on the contrecoup doctrine is that, through molecular 
oscillation, there are waves of vibration sent from the point of impact 
to the opposite pole and that these radiating waves meeting produce a 
local lesion, although they are of sufficient force to produce a fracture 
at the point of impact. Other theories are that, through the influence 
of hydrostatic pressure carried through the brain and cerebrospinal 
fluid, the bone is fractured at a point opposite that of impact. 

Rawling's Theory of Direct Violence. — From an investiga- 
tion of over 300 cases of basal fracture Rawling has obtained the fol- 
lowing results : In about 30 per cent, of cases it was possible to show 
that the fractures of the base were direct extensions from fractures of 
the vault (Aran's theory of irradiation). In about 5 per cent., the 
fracture resulted from falls upon the buttocks and from blows applied 
10 the angle of the jaw. In over 60 per cent, of cases the fractures 
were the result of direct violence applied at or near the basic level, the 
line of fracture passing across the base in the general line of the 
applied force. Tie also considered that all blows applied at or near the 
basic level tends " primarily to involve the weaker area, the base, pass- 
ing secondarily upward on to the vault." 

Rawling's rules with respect to the probable line of transbasal frac- 
ture from a study of over 300 cases are: 

'• Probable resultant basic fracture varying with the direction, etc.. 
of the applied force: (1) Force applied to the median frontal region 
(Fig. 141). The fracture passes backward from the perpendicular 
plate of the ethmoid, thence between the optic foramina to the body 
of the sphc,v.id. The fracture diverges to the opposite side, and. 
tearing off the posterior clinoid process, passes along the petro-occipital 
suture to the jugular foramen, being then continued on the other side 



FRACTURES OF THE CRANIUM 



135 



of that foramen along the masto-occipital suture, and again to the vault. 
"(2) Force applied to the lateral frontal region, in the situation 
of the external angular frontal process (Fig. 145). The fracture 
passes along the anterior fossa towards the sphenoidal fissure, tearing 
away the anterior clinoid process, and again comminutes the roof of 
the sphenoidal sinus. Progressing onwards with or without fractur- 
ing the posterior clinoid process, the fracture passes either along the 
anterior part of the petrous bone at its junction with the greater wing 
of the sphenoid towards the opposite middle and external ears, or 




Fig. 144. — Line of fracture of base, from force applied to the median frontal region. (After Rawling.) 

Fig. 145. — Line of fracture of base, from force applied to the lateral frontal region, near the external 

angular frontal process. (After Rawling.) 



along the petro-occipital suture to the jugular foramen, and is con- 
tinued along the masto-occipital suture as in the previous case. 

"(3) Force applied to the region of the external ear (Fig. 146). 
The fracture passes across the roof of the bony auditory meatus 
towards the junction of the anterior and inner walls of the middle ear, 
the membrane undergoing a variable amount of destruction and dis- 
placement. The fracture is then continued across the tegmen tympani, 
and, after following the petrosphenoidal suture reaches the foramen 
lacerum medium, being again continued on the opposite side of that 
foramen to the sphenoidal body. Thence it pursues one of two courses. 
Most commonly the fracture passes backwards obliquely to the oppo- 
site middle and external ears, following a course similar to that 
already indicated. 



130 



TREATISE OX FRACTURES 



" (4)Force applied to the mastoid region (Fig. 147). The frac- 
ture follows the occipitomastoid suture to the jugular foramen, and is 
again continued to the opposite side of that foramen along the petro- 
occipital suture towards the apex of the petrous hone. It then passes 
across the sphenoidal body to the sphenoidal fissure of the opposite 
side, and so across the anterior fossa. It is especially common in this 
particular variety of fracture to find fissures diverging from the region 
of the sphenoidal sinus forwards towards the cribriform plate of the 
ethmoid, these fissures usually passing between the optic foramina. 

" This fracture is also peculiar in that, when the degree of separa- 
tion along the occipitomastoid suture is excessive, there is special 




Fie. [46.— Lines of fracture of base, from force applied in the region of the external ear. a-a the 

„ ,. ., •typical" basic fracture. (After Rawling.) 

I- 1C. 147.— Line of fracture of the base, from force applied in the region of the mastoid. (After Rawling.) 

liability to a tearing of the lateral sinus wall as the sinus begins to turn 
downward- and inwards. 

"(5) Force applied to the lateral occipital region (Fig. 148). The 
fracture passes across the thin cerebellar fossa and strikes the foramen 
magnum immediately behind the condyle. Starting again from a simi- 
lar point on the opposite side of the foramen, the fracture passes out- 
wards to the jugular foramen. Two courses arc now possible: the frac- 
ture cither run- outward- aero-- the body of the petrous, 'external' 
to the internal auditory meatus, and. cutting across the facial nerve in 
the region of the geniculate ganglion, finally terminates in the roof 
of the middle car. or else passes along the petro-occipital suture to the 
foramen lacerum medium, the sphenoidal fissure, and the anterior 
fossa as in the previous case. 



FRACTURES OF THE CRANIUM 



137 



"(6) Force applied to the posterior occipital region (Fig. 149). 
The resultant fracture varies according to the direction of the applied 
force. A force which is applied to the transverse axis of the skull 
results in a fracture, which, on reaching the posterior margin of the 
foramen magnum, is continued again on the opposite side of the fora- 
men along the dorsum ephippii. When the force is more oblique in 
direction, as is usually the case, the fracture traverses the thin cerebel- 
lar fossa to the outer margin of the jugular foramen, and then follows 
one of the two courses indicated in the previous case. 

" More commonly the fracture cuts across the petrous bone." 



Fig. 148. 



Fig. 149. 




Fig. 148. — Line of fracture of the base, from force applied to the lateral occipital region. (After 

Rawling.) 
Fig. 149. — Lines of fracture of the base from force applied to the posterior occipital region. (After 

Rawling.) 

Symptoms of Fracture of Vault of Cranium. — As a rule the sub- 
jective symptoms are of little use in arriving at a diagnosis of sus- 
pected fracture of the skull. Fracture may show no special symptoms 
different from those associated with various forms of intracranial 
injury. 

Fractures of the vault without intracranial lesions are at times very 
difficult to diagnose. This is especially true in those which are un- 
accompanied by wounds of the scalp. When there is a circumscribed 
fracture of the vault there is generally a scalp wound through which 
the skull may be directly examined and a proper diagnosis made. In 
these patients a digital examination should be made after thoroughly 



138 TREATISE OX FRACTURES 

cleansing the wound: if necessary the wound should be enlarged for 
the purpose. Fissured, depressed, comminuted, and perforated fract- 
ures may thus readily he recognized. In closed fractures the diagnosis 
may be obscured by the coincidence of a subaponeurotic or subperi- 
cranial hematoma. The differential diagnosis of these two conditions 
is not always easy without exploration. It is justifiable to incise the 
scalp for diagnostic purposes, whenever there are symptoms pointing 
to probable depression of fragments or localized intracranial injury, or 
when the character of the traumatism makes it likely that the bone may 
he broken. An aseptic incision of the scalp is practically without 
danger ; but an undiscovered fracture, particularly of the punctured 
kind, may lead to secondary epilepsy or other serious sequel. When 
there is doubt as to the treatment to be pursued because the existence 
of fracture is not established, it is wise to incise the scalp for explora- 
tion. In intracranial injury the symptoms may be due to the occur- 
rence of cerebral laceration, or cerebral pressure from fragments or 
from blood clots resulting from damage to the middle meningeal artery 
or other vessels. In addition there may be fixed pain in certain regions, 
symptoms of compression as shown by combined or partial paralysis of 
the opposite side of the body, late evidence of encephalitis, or suppura- 
tion. The symptoms of cerebral concussion, cerebral irritation, and 
cerebral compression will be referred to briefly later. 

All fractures of the vault should be radiographed in several dif- 
ferent directions and the diagnosis of a fracture may be facilitated by 
this means. When radii igraphy is not available the surgeon should not 
allow the patient to suffer because he is too timid to cut down upon the 
injured region. It is proper to open the scalp to examine the bone, and 
to trephine the bone to examine the brain. Delay from doubt may be 
more risky by far than aseptic operation for exploration. This means 
that aseptic procedures are often necessary for diagnostic and thera- 
peutic purposes. 

Symptoms of Fracture of the Base of the Skull. — The principal 
symptoms of fracture of the base of the skull are hemorrhage, the 
escape of cerebrospinal fluid, or of brain matter, the exit of air from 
the air sinuses into the surrounding tissues, disturbance of cranial 
nerves, pupillan changes, and temperature changes. 

Most of the symptom^ may be grouped in relation to fractures 
involving one or more of the fossae of the skull. 

.Interior Fossa. — Hemorrhage from the nose or mouth is gener- 
ally present in fracture of the anterior fossa involving the cribriform 
plate of the ethmoid. Retinal hemorrhage is observed when there is 
associated hemorrhage into the subarachnoid space. Orbital hemor- 
rhage, causing proptosis, lias its origin in a fracture associated with 
injurs- to tin- cavernous sinus or internal carotid artery, in a fracture 



FRACTURES OF THE CRANIUM 139 

of the orbital walls and laceration of the ethmoidal vessels, or in a 
fracture of the sphenoidal body complicated by a fistula between the 
cavernous sinus and internal carotid artery. Palpebral, peripalpebral 
and subconjunctival hemorrhage is not always diagnostic of fracture 
involving the anterior fossa. It may, however, be present in fracture 
involving the perpendicular plate of the frontal or the cribriform plate 
of the ethmoid bone. 

Fleming reported twelve cases of fracture of the skull, eleven of 
them being fractures of the base, and in all of these there was retinal 
hemorrhage. 

Middle Fossa. — Hemorrhage may occur from the mouth or ear. 
This is possible because most fractures of the middle fossa involve the 
external auditory canal, the inner and anterior walls of the middle ear, 
the membrana tympani. The blood escaping from the ear may be 
derived from the vessels of the lining membrane of the external and 
middle ears, from the tympanic vessels, from the lateral sinus, or from 
the middle meningeal artery. Profuse and long-continued hemorrhage 
from the external ear generally means injury to the lateral sinus or 
middle meningeal artery (Figs. 150 and 151). 

Crandon and Wilson give the following statistics in reference to 
hemorrhage from the ears, nose and mouth, and mortality in fractures 
involving the middle fossa : 

Hemorrhage from the ear 281 170 111 39 per cent. 

Hemorrhage from both ears 47 16 31 66 per cent. 

Hemorrhage from the nose 44 17 27 61 percent. 

Hemorrhage from the mouth 168 72 93 33 per cent. 

D wight has shown from a study of 146 cases of fractures of the 
skull, studied at autopsy, that in 69 per cent, of cases of fracture of 
the middle fossa there was bleeding from the ear, and that in 29 per 
cent, of cases there was an associated laceration of the middle menin- 
geal artery. 

Hemorrhage from the mouth may have its source in lacerations of 
the sphenoidal or pharyngeal vessels, or from the internal carotid artery 
or cavernous sinus, complicating fractures of the sphenoid body and 
laceration of the pharyngeal wall. 

Hemorrhage in the temporal region is generally seen in f racture in- 
volving the temporal fossa, the blood being either confined to the 
temporal region, forming a temporal hematoma, or it may be diffused 
throughout the subaponeurotic space. 

Posterior Fossa. — Hemorrhage in fracture of this fossa is often 
late in appearing, and is frequently confined to the subtentorial region ; 
if the discoloration does not involve the soft parts, the hemorrhage 
may make itself evident as a boggy ecchymotic area diffused over the 
posterior surface of the scalp, the neck, and the mastoid region. 



140 



TREATISE OX FRACTURES 



A flow of cerebrospinal fluid may take place from the nose, mouth, 
or ears, and is generally diagnostic of fracture of the base of the skull, 
associated with rupture of the overlying dura and arachnoid mem- 
branes. The source of the fluid is the subarachnoid spaces. Crandon 
and Wilson reported 27 instances in which escape of cerebrospinal 
fluid was present out of 530 cases. Phelps found 13 in a series of 286 
cases of fracture of the base ; and Anna Heer recorded 58 cases of 
fracture of the base, in 2j of which there was an escape of cerebro- 
spinal fluid from the ear and in 2 from the nose. 

Fractures involving- the anterior fossa may be associated with the 
escape of cerebrospinal fluid from the nose, in which case there is 




Fir.. 150.— Fracture of the base with laceration of the carotid arteries. (After Rawling.) 
FIG. 151.— Fracture of the base with laceration of the cavernous sinus. (After Rawling.) 

illy a fracture of the cribriform plate of the ethmoid. The 
escape of cer< brospinal fluid from the nose, mouth, or ears may be seen 
in fractures involving the middle fossa. The presence of fluid flowing 
from the external auditory meatus generally means fracture of the 
middle fossa. Rawling is of the opinion that the escape of cerebro- 
spinal fluid is an infrequent symptom of fracture of the middle fossa: 
but Mates that fractures, originating in the posterior fossa, may cut 
across the petrous portion of the temporal bone in such a manner as 
to sever the seventh nerve and to tear the dural and arachnoid pro- 
longation, of that nerve. In such lesions there will be a discharge of 
cerebrospinal fluid from the ear, if the tympanic membrane is ruptured; 
but if there 1, no injury to this membrane, the escape of cerebrospinal 



FRACTURES OF THE CRANIUM 141 

fluid will take place from the nose or nasopharynx by means of the 
Eustachian tube. 

The escape of cerebrospinal fluid may begin immediately after the 
injury and may be very profuse, von Bergmann states that in some 
cases there may be from 150 to 200 grammes collected in twenty-four 
hours, and Stimson refers to a case in which 63 ounces were collected 
in four and one-half days. Sir W. MacCormac reports a case in 
which 10 pints escaped within five hours. The cerebrospinal fluid 
escaping from the nose, mouth, or ears should be of the same chemical 
character as that found normally in the subarachnoid spaces. It should 
be alkaline in reaction, contain a trace of albumin, be rich in sodium 
chloride, and should show a trace of a reducing substance allied to 
pyrocatechin. The escape of cerebrospinal fluid from the nose, mouth, 
or ears may be contaminated with normal discharges from these orifi- 
ces, and render the tests noted valueless. Generally the fluid is at first 
blood-stained. Other sources of error are seen in the escape of a fluid 
which is highly albuminous and contains no chlorides, which has its 
origin from the large perilymph spaces of the labyrinth, the liquor 
cotunnii. Another source of error is a serous discharge from the 
mucous membrane of the ear or nose, which can be differentiated from 
cerebrospinal fluid by its chemical characteristics. Inflammatory dis- 
charges from these two surfaces may also be profuse and lead to 
error, or be the sources of contamination. The serum from extrava- 
sated blood may lead to error. In this instance it is not very profuse, 
is reddish, albuminous, and does not appear immediately after the 
injury. 

The escape of brain tissue is of very rare occurrence. Rawling has 
observed one case of escape of brain tissue from the nose and one from 
the ear in a series of 300 cases. Its presence is a positive sign of 
fracture of the skull and also of laceration of the dura and arachnoid. 
There is generally considerable comminution of bone, such as occurs in 
crushing injuries. In a case of one of the authors, in which the head 
was injured in an elevator accident, there was subsequent discharge of 
brain tissue from the nose. The post-mortem examination showed ex- 
tensive comminuted fracture of the base involving the cribriform plate 
of the ethmoid. The escape of brain tissue from the external auditory 
meatus necessitates a fracture involving the superior wall of the audi- 
tory canal, rupture of the tympanic membrane, and also of the dura 
and arachnoid. 

Emphysema of the surrounding soft parts may take place when the 
line of fracture involves the frontal, ethmoidal, mastoid, or sphenoidal 
sinuses, and there is a sudden increase of intrasinal air pressure. This 
condition is seen most frequently after fracture of the frontal bone 



142 TREATISE ON FRACTURES 

involving the frontal sinus, very rarely after fracture involving the 
sphenoid bone and mastoid process. The emphysema may be circum- 
scribed or it may be diffused. It is circumscribed when the overlying 
pericranium is not torn, and it may be diffuse when the pericranium is 
torn. At times the emphysema in fracture involving the frontal sinus 
may spread over the face, neck and chest; in fracture involving the 
mastoid region it may spread through the subaponeurotic space to the 
scalp and the cellular tissue of the neck. Its presence is readily deter- 
mined by palpation, which reveals the peculiar crackling. It does not 
always appear immediately after injury. It may be made to increase 
by sneezing and forcible breathing efforts ; the location of the primary 
swelling is generally indicative of the source of the air. 

Involvement of cranial nerves may be the result of fractures of 
the base of the skull in which the line of fracture invades the canals 
through which the nerves make their exit from the skull, of laceration 
from a detached fragment of bone, or of compression by bone or blood 
clot (Fig. 152). The disturbance of nerve function may be due to 
laceration without fracture or to an injury at the central origin of the 
nerve, to general intracranial pressure. The involvement of nerves is 
apt to be immediate. A secondary form of paralysis may occur due to 
inflammatory changes, pyogenic in character, along the nerve trunk. 
This may be followed by grave results owing to infection at the base 
of the brain. 

Injuries to nerves are frequently observed to occur in groups: the 
seventh, eighth and sixth; the fifth and third; the ninth, tenth and 
eleventh. From the character of the paralysis one can frequently de- 
termine the situation of the fracture. The facial and the abducens 
nerves are most frequently involved in fractures of the base. 

Fractures of the anterior fossa may involve the olfactory nerve, as 
in fracture of the cribriform plate of the ethmoid. Disturbance of the 
Optic nerve function is generally due to compression or crushing of 
nerves by a displaced clinoid process, rarely by fracture through the 
Optic foramen, and occasionally by hemorrhage into sheath of nerve. 
Cullen reports 17 cases of compression of optic nerve from fragments 
near the optic foramen; Holder reports fracture of bones forming 
foramen in 53 of 86 cases of fracture in this region. Involvement of 
the ophthalmic division of the trifacial generally is the result of hemor- 
rhage into sheath of nerve; of the nasal nerve suggests fracture of the 
cribriform plate; of the supratrochlear and supraorbital branches in- 
dicates fracture of vertical plate of frontal bone. The oculomotor and 
trochlear nerves are rarely injured, but may be affected through hemor- 
rhagic extravasation. Fracture of the middle fossa may involve the 
maxillary awl mandibular divisions of the trifacial but is very rarelv 



FRACTURES OF THE CRANIUM 



143 



seen, requiring fracture of the walls of the foramen ovale and foramen 
rotundum. Involvement of the abducens points to fracture of the 
dorsum ephippii or to hemorrhagic infiltration of nerve sheaths. 
Schroder observed 58 cases of abducens paralysis in fracture of the 
base, 48 immediately following the injury. Irritation, paresis or palsy 
of the facial suggests fracture of petrous bone at the external or in- 
ternal auditory meatus. When a nerve is cut across in the region of 
the ganglion the paralysis is permanent ; in hemorrhagic infiltration of 
nerve sheaths, paralysis is not permanent. Involvement of the auditory 
occurs in fracture of the petrous bone extending from the internal ear 
through the labyrinth, tympanic cavity and roof of the auditory canal. 
It is generally accompanied by paralysis of the facial nerve and the 



Fig. is3. 



Fig. 152 




FrG. 152. — Shows position of cranial nerves and their liability to laceration in various fractures at the 

base of the skull. The numbers are the names of the nerves. 

Fig. 153. — Cerebral pressure from an extradural clot from hemorrhage from the posterior branch of 

the middle meningeal artery. (After Rawhng) . 



lesion is permanent. Kohler observed paralysis of the facial nerve 22 
times in 48 cases of fracture of the base of the skull. Anna Heer 
records paralysis of the facial nerve 10 times in 11 cases of injury of 
cranial nerves, and paralysis of the acoustic nerve 9 times in 58 cases 
of fracture of the base of the skull. 

Fractures of the posterior fossa may involve the facial and auditory 
nerve by fracture of the outer angle of the jugular foramen and petrous 
bone. The glossopharyngeal, pneumo gastric, and spinal accessory 
nerves are seldom injured on account of the rarity of fracture at the 
jugular foramen and of the protection afforded by their dural sheaths. 
Intracranial injury to these nerves is either by bullets or by fracture of 
the jugular foramen. The hypoglossal is rarely injured intracranially. 



144 TREATISE ON FRACTURES 

A case is reported by Stierlein of paralysis of the hypoglossal with 
the pneumogastric nerve; and a case is recorded by von Bergniann of 
paralysis of the hypoglossal with the spinal accessory nerve. 

Intracranial Hemorrhage. — Intracranial hemorrhage may arise 
from injury to the following vessels : the middle meningeal artery and 
its accompanying veins; the internal carotid artery; the sinuses of the 
brain, the principal of which are the superior longitudinal, the lateral, 
the transverse, the cavernous and the torcular Herophili, and the pia 
arachnoid vessels. 

Injury to the middle meningeal artery may be produced by penetrat- 
ing wounds, by depressed fractures of the cranium, by fractures ex- 
tending from the base, and as a result of the various traumatisms which 
produce fracture of the skull. It occurs most frequently in conjunction 
with comminuted fractures of the temporal region. Cases have been 
reported in which an apparently trivial blow has resulted in laceration 
of the artery without injury to the bone. 

From the injury to the artery hemorrhage takes place, and may be 
extradural (Fig. 153), subdural or both. As a rule the bleeding is 
extradural; but when the dura is torn, the extravasation may occur in 
both places at the same time. The blood escapes under a pressure of 
80 to 100 mm. of mercury, and hemorrhage continues until the ex- 
travasation produces such intracranial pressure that the blood-pressure 
is equalized, until a thrombus forms, or until death occurs from cerebral 
compression. The extravasation may amount to from 4 to 8 ounces. 
Kronlein divides the resulting hematomas into diffused and circum- 
scribed. The former may extend over one-half of the brain; the latter 
is subdivided into three varieties dependent upon the part of the artery 
injured ( Fig. 154) : anterior hematoma (" frontotemporal "), middle 
hematoma ( " temperoparietal " ), and posterior hematoma (" parieto- 
occipital " ). The anterior is due to rupture of the anterior division 
of the anterior branch of the artery and is very rare, the middle is due 
to rupture of the trunk or both principal 'branches of the artery and is 
mosl common, and the posterior is due to rupture of the posterior prin- 
cipal branch of the artery and is very rare. Rawling states that hemor- 
rhage from the middle meningeal artery was found in 20 per cent, of 
all the cases of fracture of the skull studied, and that in 45 per cent, of 
the cases the middle fossa was involved. Dwight found in 149 cases 
of Fracture of the skull observed at autopsy that there was middle 
meningeal hemorrhage in +<) cases (29 per cent.), while Nichols re- 
ported the same condition in 1 i cases out of 32 autopsies of fracture 
of the skull I 34 per cent. ). 

The diagnosis of hemorrhage depends in a great measure upon 
whether there is an external exit to the bleeding. If tins exists the 



FRACTURES OP THE CRANIUM 



145 



diagnosis may readily be made. When, however, there is no external 
bleeding, there are cardinal symptoms on which our diagnosis may be 
based. 

A free interval. — The interval between the time of injury and 
the onset of symptoms varies. It depends upon the extent of injury, 
the size of the vessel, the presence or absence of a depressed fracture 
of the vault, and the extent and severity of the cerebral concussion with 
its period of unconsciousness. There is, however, as a general rule a 




Fig. 154. — Kronlein's method for points of election for trephining in meningeal hemorrhage. The 
three usual areas of extravasation of blood are shown i, ii. iii. S-O, supra-orbital line; S-A, auriculo 
orbital line; V—R, vertical retromastoid line; V'—A, vertical auricular line; V"-2, vertical zygomatic 
line. The large circles show the points at which trephining should be performed to ligate the anterior 
and the posterior branches of the middle meningeal artery. 

lucid interval following a primary period of unconsciousness before 
the unconsciousness of compression occurs. 

Changes in the pulse. — Of great importance is the gradual change 
in the character and rate of the pulse. At first there is an increase of 
tension with slowing of the pulse-rate due to intracranial pressure, the 
vagus centre in the medulla being stimulated, so that the pulse may go 
as low as 30 to 40 per minute and the blood-pressure rise, reaching 200 
to 250 mm. of mercury. Later, from long-continued and increasing 
pressure, the vagus centre becomes exhausted and the pulse changes 
10 



146 TREATISE ON FRACTURES 

markedly in character, the blood-pressure drops, the pulse becomes 
.ar and rapid, and may reach 180 per minute. 
Res --■ — These consist in changes from the super- 

ficial respiration of cerebral concussion to the slow, labored, stertorous 
breathing of cerebral - - due to pressure upon 

the respiratory centre in the medulla. Later the breathing becomes 
Cheyi character. Hemiplegia is dependent upon areas 

of pressure over the centres of the brain innervating the parts affected. 
The extent, character and part affected are entirely dependent upon 
the location, degree of hemorrhage, and region affected. The result- 
ing symptoms - -- asist in twitchings, convulsions, spasti- 
- paralysis of the - ■:' the face, and of the upper and 
lower extremities of the side opposite to the lesion. For the various 
theories of collateral hemiplegia one should read the works of Tedder- 
house, Oppenheim. and Artner. 

Eye Changes. — Experimental compression has shown that at the 
beginning of pressure the pupil of the side affected is contracted, that 
with increase of pressure and during the stage of coma the pupils are 
dilated, the pupil of the side affected being greatly dilated and immobile. 
v<>n Bergmann found in ~o cases of rupture of the middle meningeal 
artery with pupillary changes, that both pupils were widely dilated in 
th were markedly contracted in /, there was dilatation of 
the pupil of side as the hemorrhage in 20, and dilatation of 

the pupil of the opposite side in 4. Gubler coincides with the same con- 
ns. Rawling. in a study of his cases, found that the pupils were 
equal in 46 ]>er cent, of cases, that the pupils were contracted on the 
affected side in 36 per cent, of cases, and that they were dilated on the 
affected side in 18 per o - ":ers that the alterations 

in the size of the pupil are of doubtful significance in the diagnosis of 
hemorrhage from the middle meningeal artery, and that the so-called 
Hutchinson pupil, the pupil on the affected side being dilated, due to 
direct compression of the third nerve from extra vasated blood, is rarely 
■■(]. Ophth examination showed, as a rule, the pres- 

ence of oedema of the disk, and dilatation of the retinal veins with 
raction of the arteri 

irom the intracranial sinuses are usually the result 
mnds, or are due to extensive fracture with 
minution. The hemorrhage may take place from the superior longi- 
tudinal or latera" lar Hero] hili at the vault and at 
the base from the cave- _ ff ^5 rapidlv 
thn iugh< Art the subdural space, but the syi such venous bleed- 

•n resulting 

rrhage. In the latter, symptoms of rapid 

are evident -% e le=inn when as- 



FRACTURES OF THE CRANIUM 147 

sociated with a proper site and nature of the traumatism, and with the 
character of external bleeding if any, especially if blood-corpuscles be 
present in the cerebrospinal fluid obtained by lumbar puncture. 

Proarachnoid hemorrhage is more localized than that observed in 
lacerations of intracranial sinuses, which is generally diffuse subdural 
extravasation. A localized form of subdural hemorrhage, or hemato- 
cele, is the result of bleeding from torn proarachnoid vessels, due to 
localized laceration and contusion of the cortex. The vascular injury, 
while not severe enough to lead to direct symptoms of compression, 
causes vague, indefinite symptoms such as photophobia, headache, in- 
somnia, irritability, and slight temperature changes ; later, after a lucid 
interval of from a week to a month, symptoms of compression may 
occur. If the lesion involves the frontoparietal region, aphasia, nervous 
irritability, paralysis of the face, arm or leg centres may develop, and 
later, as the hemorrhage increases and cerebral compression becomes 
greater, paralysis and coma may result. This is a very important form 
of intracranial hemorrhage, and one that is not recognized as often as 
it should be. Patients with such head injury often present signs of 
cerebral irritation, which does not progress for a week or more, and 
after observation for that period they are considered convalescent. 
Shortly afterwards, however, death may occur from an increase in 
the size of the hemorrhage and the resultant compression. 

Intracranial hemorrhage from the internal carotid artery is very 
rare. This artery may, however, be ruptured in severe fractures of 
the middle fossa, from penetrating wounds of the skull and bullet 
wounds. The rarity of intracranial injury of the cerebral portion of 
the carotid is possibly due to the amount of freedom of motion which 
is permitted it. When complete laceration of the artery occurs, the 
resulting hemorrhage is so severe that death is almost instantaneous on 
account of the accompanying lesions of the bone and the facility with 
which external bleeding occurs. In two cases reported by Rawling, 
death was instantaneous, while Marchant reports a case of a man in- 
jured by a sabre blow who lived sixteen days. 

Injury to the Brain. — The most important complications of fract- 
ure of the skull are injuries to the brain itself. While all fractures of 
the skull are not accompanied by injury to the brain, and severe injury 
may exist without fracture, it can he well understood that severe 
fractures of the skull are generally accompanied by considerable 
cerebral injury. The various lesions affecting the brain are concussion, 
contusions, cerebral irritation, and compression. Of the above com- 
plications of fracture of the skull, compression due to hemorrhage and 
to depressed fracture have been considered. Concussion and contusion 
will be briefly alluded to, but for a more detailed consideration the 
reader is referred to special works dealing with these conditions. 



14 8 TREATISE ON FRACTURES 

Cerebral Concussion.— M any theories have been advanced to 
account for a train of cerebral symptoms, of which the chief one may 
be said to be a primary period of unconsciousness, which is generally 
designated as cerebral concussion. This may be described as an acute 
cerebral anaemia and sudden inhibition of the vasomotor centre leading 
to a sudden fall in blood-pressure. That concussion in this mild degree 
may exist without subcortical lesion or laceration of brain tissue or 
blood-vessels is evident, and that in some cases a fatal result may 
ensue from this alone is evident from the reports of autopsies at which 
no demonstrable lesion, microscopic or macroscopic, could be detected. 
Other cases may show focal areas of hemorrhage and contusion. As 
a result of the varying theories as to the pathological change present 
in this condition, two schools have been established : 

That concussion may exist without extravasation or laceration of 
brain tissue (von Bergmann), and that concussion is represented 
pathologically by a condition of minute contusions scattered through- 
out the brain tissue and that molecular changes take place in the nerve 
cells (Kocher). 

Symptoms of Concussion. — Sudden loss of consciousness accom- 
panied by a fall of blood-pressure, subnormal temperature, general 
pallor, and moisture of the skin follow the receipt of the trauma. This 
state is followed by a stage of reaction, in which consciousness returns, 
the temperature rises, the face and the skin generally become hot, 
moist and suffused, the blood-pressure rises, and there results head- 
ache, restlessness, and even delirium. In the more severe cases the 
period of unconsciousness may be prolonged and the patient pass into 
a state of coma with all the evidences of severe intracranial pressure 
due to cerebral oedema. In this latter class of cases, the extracranial 
vessels are dilated, there is marked increase of cerebrospinal fluid and 
generalized cerebral oedema, more marked at the base. Rawling refers 
to a fatal case of concussion in which at operation the surface of the 
cortex was obscured by an (edematous pia-arachnoid one-quarter of an 
inch in depth. In the mild cases of concussion the pupils are equal in 
reaction to light, the patient may be aroused by supra-orbital pressure, 
the pulse is rapid ( i 10 i_>o), the blood-pressure lowered, and the tem- 
perature subnormal. There may be temporary loss of control of 
bladder and rectum, but the superficial and deep retlexes are not 
abolished. With reaction the patient slowly returns to consciousness, 
the pulse decreases in rate, the blood-pressure increases, the pupillary 
reflexes return, vomiting may take place, the temperature may go 
above normal, and there is a period of headache and symptoms point- 
nerally to increased intracranial tension, the result, in all prob- 
ability, of cerebral oedema. 



FRACTURES OF THE CRANIUM 



149 



The Relationship of Temperature Changes to Head Injuries. — 

This subject has been of great interest for many years and many facts 
have been gathered on the subject by Broca, Banti, Guyon, Wol- 
sham, Rawling, and others. The most important facts have been de- 
duced by Rawling from the observation of over 300 head cases in 
which accurate records of temperature were made and the patients 
carefully observed during their illness. He presents the following 
deductions: 

" ( 1 ) That, for a variable period of time after the injury, the tem- 
perature is always subnormal — sometimes so low that it cannot be 
registered. This is the period of shock (Fig. 155). 



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"(2) That the patient may die in this state of shock, but that, if he 
lives, reaction takes place and the temperature rises (Fig. 156). 

"(3) That this rise in temperature is, in fatal cases, rapid and 
progressive. In one case the temperature rose 6° in seven hours, in 
another 8° in four hours. Death occurs when the temperature is at its 
highest. The thermometer may register as high as 106 , and even 
more when taken in the rectum (Fig. 157). 

"(4) That the temperature may rise to a moderate height, and 
there become stationary. This is the crisis of the case. A subsequent 
fall in temperature generally indicates recovery, a further rise usually 
points to a fatal termination (Figs. 158 and 159). 



150 



TREATISE ON FRACTURES 



"(5) That the rise of temperature is independent of any special 
osseous lesion, since similar changes are observed in fractures of the 
vault and in fractures of the base. 

"(6) That lacerations of the brain are present in the majority of 
cases in which marked temperature changes are observed, but that the 
changes in temperature are totally independent of any special regional 
brain injury (Fig. 160)." 

Cerebral contusion is the result of external violence applied to 
the skull and transmitted by the latter, producing varying degrees of 
injury to the brain substance, from mere bruising to laceration, and 
showing clinically all the evidences of cerebral irritation. The injury 




may consist of laceration of the pia-arachnoid vessels, or of minute 
bruises, diffuse lacerations, or even macroscopic destruction of brain 
tissue. There may be only small areas of hemorrhage, but the injury 
may involve areas of the brain the size of an egg, or include one or 
more lobes. Contusions are most apt to involve the cortex, and that of 
the base more often than that of the vault. The pons, crura cerebri, 
cerebellum, and medulla are rarely involved. The most frequent sites 
of injur}- are the frontal and the temporosphenoidal regions. Kron- 
lein considers that the accompanying contusion of the brain generally 
is due to the inflicting force and is most severe at the poles of the line 



FRACTURES OF THE CRANIUM 



151 



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Fig. 157 — Temperature chart showing rapid and progressive rise cf temperature in fracture of the 
base, followed by death fourteen hours after admission. 



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Fig. is8. — Chart showing moderate elevation of temperature, which remains stationary, followed by 
recovery. 



152 



TREATISE ON FRACTURES 



of force. Hence it happens that in longitudinal fractures of the base 
the frontal lobe of the cerebrum and the lobes of the cerebellum are 
injured: in transverse fractures the two temporal lobes are contused; 
and in oblique breaks the frontal lobe of one hemisphere and the 
parietal lobe of the other hemisphere suffer damage. Deviations from 
this rule are due to the irregularities of the cranial base and of the 
brain substance itself. In localized comminuted fractures of the vault, 
the contused area is immediately beneath the area involved. Multiplicity 
of lesions are explained by the semi-fluid brain consistency and known 
hydrodynamic laws. In addition to the injury of the brain itself there 
is frequently laceration of the meninges with hemorrhage into, be- 



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I"k.. 1 59. — Temperature chart showing moderate rise followed by fall to below normal, ending fatally. 

tween, or outside the brain membranes. Hemorrhage may be supra- 
dural, subarachnoid, or subpial, depending upon the meninges lacerated 
and the degree and extent of laceration of the meningeal membrane's 

Symptoms of Contusion. — Very frequently contusion of the brain 
is accompanied by symptoms of concussion and followed by those of 
compression so thai perfect differentiation is impossible. Often the 
lesions are multiple and the clinical picture becomes obscure, because 
the symptoms of contusion indefinitely merge into those of compression 
from accompanying hemorrhage. On the oilier hand, there may be 
rather extensive lesions of the brain tissue and injury to the meninges 



FRACTURES OF THE CRANIUM 



153 





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Fig. 160. — Temperature chart in a case of fracture of the base and marked laceration of the brain, 
showing variable temperature changes ending in ultimate recovery. 



154 TREATISE OX FRACTURES 

without any definite localizing symptoms. Again, the symptoms of 
cerebral contusion may he similar to those of a purulent encephalitis 
or meningitis. 

As a rule there is an initial stage of unconsciousness due to con- 
cussion, which may rapidly pass and give place to symptoms of cerebral 
irritation. The chief symptoms of the latter condition are a rapid 
increase of blood-pressure, shown by high tension, fairly rapid pulse, 
marked mental irritation, and occasionally violence requiring restraint. 
The patient resists efforts to draw open the eyes, pupillary and retinal 
examinations are impossible, headache is severe, restlessness is ex- 
treme, he generally lies on his side with legs drawn up. there may be 
involuntary passage of urine and faeces, the temperature is above 
normal, and the skin is hot and dry. Lumbar puncture generally shows 
blood in the cerebrospinal fluid. The symptoms of contusion are very 
pronounced, convalescence is prolonged, and patients complain for a 
long time of headache, mental irritability, and at times of depression. 
The mental character may alter and the end result mav be traumatic 
neurasthenia, traumatic cephalalgia, or epilepsy. 

The primary state of contusion may be followed by that of compres- 
sion — acute when due to rapid hemorrhage, delayed when due to slow 
hemorrhage, to abscess, to subdural hematocele, or to tumor formation. 

Diagnosis of Fracture of the Skull.— Fractures of the Vault. 
— In closed depressed fractures of the vault the diagnosis may be made 
from the character of the depression felt by palpation, the nature of 
the injury, and the symptoms of intracranial complication. Linear 
fractures may at times l>e recognized by the tenderness over the line of 
fracture or. a- suggested by von 15ergmann. by the changed percussion 
note, if there is any gaping of the fissures. Differentiation of de- 
pressed fracture from subaponeurotic extravasation should be care- 
fully made by the peculiar feel to infiltrated area of the latter, which 
may be indented with moderate pressure. In open fractures, depressed 
and comminuted conditions may readily be recognized. Linear frac- 
tures may be diagnosed by oozing, which may be seen issuing between 
the wall- of the fissure, by the slight unevenness of their edges, and by 
the presence of a fissure not at the site of a suture. 

Fractures of the Base.— In fractures involving the base of the 
skull, the diagnosis i- made more from the symptoms of the injury to 
the intracranial contents than upon any possible evidence obtained by 
observation of the fracture itself. Fractures of the base are deter- 
mined by the evidences of hemorrhage, intra- and extracranial, the 
escape of cerebrospinal fluid, the escape of brain matter, localized or 
diffuse emphysema due to rupture of the air-containing sinuses, the in- 
volvement of cranial nerves, the development of cerebral (edema, puru- 
lent encephalitis and meningitis, the presence of blood in the cerebro- 



FRACTURES OF THE CRANIUM 155 

spinal fluid obtained by lumbar puncture, and by the complicating 
symptoms of cerebral concussion, contusion, or compression. Radi- 
ography may be of extreme value, and a study of X-ray plates taken in 
two planes should be a routine practice in doubtful cases when possible. 

Differential Diagnosis of Coma Due to Head Injury from Other 
Forms of Unconsciousness. — While it may be possible to readily 
diagnose traumatic coma from a history of the accident and the va- 
rious evidences of injury present, the surgeon at times is unable to 
obtain any history or to notice at first glance evidence of injury. In 
these cases the coma due to concussion, contusion, and compression 
should be differentiated from that which occurs in alcoholism, in apo- 
plexy, in opium poisoning, in uraemia, in epilepsy, and in diabetes. A 
correct diagnosis in many cases can be made only after a thorough 
examination of the patient. This examination should begin at the 
head and include the entire body. In fracture of the skull there may 
be evidence of external injury to the vault, in the frontal, temporo- 
parietal, or occipital regions, or at the level of the base of the brain. 
Bleeding from the nose, mouth, or ears, or the escape of cerebrospinal 
fluid or brain tissue will clear up the diagnosis. The presence of blood 
in the cerebrospinal fluid obtained by lumbar puncture is also suggestive 
of fracture at the base combined with intracranial hemorrhage. Palsies 
from intracranial injury to nerves are suggestive of fracture at the 
base. There may, of course, be prior disease of the viscera, leading to 
unconsciousness, in addition to the injury which is suspected to be its 
cause. Lumbar puncture should not be recklessly employed. 

The presence of old scars or fresh injuries to the tongue is sug- 
gestive of epilepsy. In uraemia there is a sweetish odor to the breath, 
in diabetes the odor is typical of acetone, and in alcoholism the peculiar 
stale odor of liquor is noticeable. In apoplexy, compression, and 
trauma there may be facial palsies. In opium poisoning, diabetes and 
concussion the face is pale, peaceful, and the breathing quiet. In com- 
pression, apoplexy, uraemia and alcoholism the face is congested and 
the breathing is stertorous. In apoplexy and injury there may be 
unilateral paralysis of the extremities, limited to upper or lower or 
both, combined with exaggerated reflexes, while in alcoholism resist- 
ance to movement is marked. Convulsions suggest uraemia, epilepsy, 
or injury. Examination of the urine with the presence of albuminuria 
and casts points to uraemia, while in diabetes the urine contains sugar 
and possibly acetone, diacetic and /3-oxybutyric acids. Examination of 
the eyes is very important. The presence of paralysis of ocular 
muscles points to injury or apoplexy, while the presence of subcon- 
junctival and palpebral hemorrhage points to injury. In uncom- 
plicated fractures of the base there are no pupillary or disk changes. 
When accompanied by concussion the pupils are equal, dilated, and 



150 TREATISE ON FRACTURES 

react to light ; in contusion the pupils may be unequal, dilated, or con- 
tracted, and generally fail to react to light; but in cerebral compression 
they may be equal or unequal, dilated, and do not react to light. In 
apoplexy the pupils are generally unequal, dilated, and do not react to 
light, and in hemorrhage into the pons the pupils are pin-pointed. In 
diabetes and epilepsy the pupils are equal, sluggish, and react to light. 
In opium poisoning the pupils are contracted, equal, and do not react 
to light. In uraemia the pupils are dilated and react to light slowly. In 
alcoholism the pupils are generally normal; but in extreme stages of 
alcoholism they are usually dilated and fail to react to light. Ex- 
amination of the fundus in these varying conditions may show dis- 
tinctive changes, such as retinal hemorrhage in trauma and in arterio- 
sclerosis, the characteristics of optic neuritis in uraemia and diabetes, 
and choked disk in pressure from cerebral abscess or intracranial 
tumor. 

Examination of the pulse will give valuable information. The 
presence of atheromatous arteries will suggest apoplexy ; a high tension, 
slow pulse with relatively high blood-pressure, will suggest uraemia, 
compression, and apoplexy. The presence of a very slow full pulse 
may be indicative of alcoholism, although the pulse in this latter con- 
dition is variable. In concussion and contusion of the brain the pulse 
may be rapid, weak, and accompanied by low blood-pressure. 

The temperature shows marked variation in these conditions. In 
uraemia, concussion, opium poisoning, and epilepsy the temperature 
is normal or subnormal. In apoplexy, contusion, compression, and 
alcoholism the temperature is generally above normal, while in hemor- 
rhage into the pons there is hyperpyrexia as a rule. 

Prognosis.— Here again the question of results is dependent upon 
the accompanying lesion to the intracranial structure rather than upon 
the degree of injury to the cranium itself. Extensive fracture of the 
cranium unaccompanied by lesion of the intracranial contents may 
have a very favorable prognosis, whereas a small fissured fracture 
accompanying a small lesion of the pons or medulla is liable to have a 
sudden fatal termination. The two accompanying conditions most fre- 
quently seen in fractures of the skull that greatly determine the prog- 
nosis are infection and hemorrhage. The infections through fracture 
of the skull generally act through open wounds of the scalp and are 
usually streptococcic, staphylococcic, or tetanic in nature. Infections 
reaching the cranial contents may gain entrance through the accessory 
sinuses of the nose, the nasopharynx or external auditory meatus, and 
are generally pneumococcic in character. Fractures of the base are 
liable to more serious complications than fractures at the vault, on 
account of the nature of the violence causing Dasa ] fractures, the 
mechanism of their production, and the greater liability to injury of 



FRACTURES OF THE CRANIUM 157 

the important structures situated at the base of the brain. Among 
secondary complications may be mentioned meningitis, abscess, and 
localized haematoma. An injury apparently insignificant may prove to 
be fatal on account of the resulting meningitis or abscess. 

Hemorrhage is probably the most important complication of frac- 
tures. As stated above, this may be small in amount, but if it takes 
place in the pons or medulla death occurs very rapidly. In other cases 
the hemorrhage may be progressive until symptoms of compression 
arise and is followed by death unless operative relief is given. Intra- 
cranial hemorrhage taking place in the presence of laceration of the 
dura with free exit from the brain-case to the outside does not, as a 
rule, produce death from pressure of the bleeding. Minute hemor- 
rhages accompanied by marked oedema may cause compression, coma, 
and death. 

In depressed, comminuted fractures of the vault, death may occur 
on account of compression due to depression of fragments and hemor- 
rhage, but depressed fragments may be present and cause no symptoms 
at all. 

Battle, from a study of 168 cases of fracture of the cranium, 
places the mortality at 32 per cent. Crandon and Wilson, from a 
series of 530 cases, give a mortality of 44 per cent. Rawling states 
that of those fractures purely or mainly basic observed by him, 116 
recovered and 89 died, a mortality of 44 per cent. In a primary frac- 
ture of the vault Rawling gives the following statistics based on a study 
of 88 cases observed at St. Bartholomew's Hospital from 1900 to 1906 : 

Under the age of five 8 lived and 2 died. Mortality, 20 per cent. 

Under the age of ten 2 lived and 3 died. Mortality, 60 per cent. 

Under the age of fifteen 6 lived and o died. Mortality, o per cent. 

Under the age of twenty 10 lived and 3 died. Mortality, 23 per cent. 

Under the age of thirty 9 lived and 1 died. Mortality, 10 per cent. 

Under the age of forty 16 lived and 9 died. Mortality, 36 per cent. 

Under the age of fifty 3 lived and 7 died. Mortality, 70 per cent. 

Under the age of sixty 2 lived and 1 died. Mortality, 33 P er cent. 

Over the age of sixty 3 lived and 3 died. Mortality, 50 per cent. 



59 lived and 29 died. Mortality, 37 per cent. 

The mortality also varies according to the fossa involved in frac- 
tures of the base of the skull. Rawling considered that fracture of the 
middle fossa presents the greatest dangers. This fossa is involved 
with great frequency in fractures of the base ; and the injuries are 
dangerous on account of the avenues of possible infection leading into 
it from the nasopharynx and the ear. The hemorrhages which may 
occur in fracture involving this fossa are from the middle meningeal 
and internal carotid arteries and cavernous sinus and are always grave. 
Leonard Hill, however, considers that involvement of the posterior 



158 TREATISE ON FRACTURES 

fossa is the most dangerous on account of the fact that the main vital 
centres are situated in the region of the fourth ventricle and that any 
increase in intracranial pressure exerts its effect most rapidly when the 
lesion is situated beneath the tentorium cerebelli. 

Burkhard records 42 recoveries in 43 cases of uncomplicated fract- 
ures of the skull, and Wagner records only two deaths among 83 recent 
compound fractures of the skull, von Bergmann considers that patients 
suffering with fracture of the skull who are not killed instantly are in 
the greatest degree of danger during the first twenty-four to forty- 
eight hours. Wagner records 2$ cases surviving this period in which 
only one death occurred. 

In regard to prognosis, Rawling considers that all cases of head 
injury may be grouped into four classes, dependent upon the tem- 
perature changes as follows (Fig. 155-160). 

" Group I. The temperature, at first subnormal, undergoes a rapid 
and progressive rise. Prognosis most unfavorable. 

" Group 2. The temperature, at first subnormal, rises gradually to 
ioi° or 102 c and there ' marks time.' This hesitancy marks the crisis 
of the case, further elevation indicating a fatal result, whilst a fall 
offers every hope of recovery. 

" Group 3. The temperature, at first subnormal, rises to normal 
and remains at that level. Prognosis very favorable. 

" Group 4. The temperature, at first subnormal, remains su1>- 
normal. The condition of shock persists, and the prognosis is most 
unfavorable." 

Xot only does Rawling consider the temperature chart as of in- 
valuable help in the prognosis, but it is also a guide in the treatment 
of the case. This will be referred to later under treatment. 

Eguchi states that from 1.3 to 4.7 per cent, of all skull injuries 
admitted to the reserve hospitals of Japan during the Russo-Japanese 
War were followed by traumatic epilepsy. In these, injuries to the 
bone and dura mater produced irritation of the brain. The shortest 
period from the day of injury to the beginning of the epilepsy was 3 
days : the longest was 442 days, the average 161 days. Operation gave 
good results in Eguchi's cases. A cure was obtained in 1 1 cases, or 
90.9 per cent., and no results in 1 case, or 9.1 per cent. Death followed 
operation in this case from the rupture of an aneurism. 

A. C. Burnham reports the following statistics based upon the 
observation of thirty-five cases of compound fractures of the base of 
the skull treated at the Presbyterian Hospital. Xew York. Cases which 
were surely basal fractures, but in which there was some doubt as to 
the diagnosis of compound fracture, were not included .in this report. 
Of these 35 patients 14 died and 21 recovered, a general mor- 
tality of 40 per cent. Six patients died during the first forty-eight 



FRACTURES OF THE CRANIUM 159 

hours, all in primary shock as a result of the injury. Eight patients 
died after the third and before the fourteenth day, after having par- 
tially or wholly recovered from the initial shock of the accident. Of 
these 8 patients 5 died of meningitis. The causes of death and the day 
on which it occurred in the fatal cases are as follows : 5 died of 
meningitis — on the fourth 2, on the sixth 2, and 1 on the thirteenth 
day. respectively. Two patients died of bronchopneumonia on the 
fourth day. One patient died on the tenth day after secondary hemor- 
rhage and operation. It can readily be seen from the above figures 
that even in those patients surviving from the initial shock following 
compound fracture of the base of the skull, the mortality (in this 
series 25.5 per cent.) is high. 

Treatment. — The treatment of fractures of the cranium must de- 
pend upon whether the fracture is of the vault or of the base; closed 
or open ; depressed, comminuted, fissured, or punctured ; associated or 
not with concussion, contusion, intracranial hemorrhage, or oedema ; or 
is open to infection at the base through the nose, pharynx, or ear. 
^ "hen the fracture is of the vault or base and unaccompanied by any 
intracranial lesions, the rules of treatment are very simple. When 
complications exist the treatment depends upon the character, severity, 
and degree of injury to intracranial contents and the avenues of pos- 
sible infection. In fracture of the vault the indications for operative 
intervention are usually distinct and clear-cut. It is generally per- 
formed for depression of fragment or hemorrhage from the middle 
meningeal artery or longitudinal sinus; in fractures of the base our 
indications for operation are not dependent so much upon the injury to 
the cranium itself, but rather upon critical intracranial complications. 

General Lines of Treatment. — In all closed fractures of the vault 
or base one should adopt some rational form of general treatment. 
Operation should only be considered when there is some well-defined 
indication for the operative procedure or a degree of uncertainty 
making exploratory incision wise. Then it should be performed with 
the hope of giving the patient a chance for immediate recovery or 
as a means of preventing remote effects of head injuries, such as trau- 
matic neurasthenia, chronic cephalalgia, and epilepsy. 

The surgeon should be guided by the general condition of the 
patient, the character of the injury, the location of the fracture, the 
presence or absence of intracranial complications, the blood-pressure, 
the character of the pulse, the respiration, and the degree and depth of 
coma present. 

The patient should be placed in bed, in a room alone if possible ; 
and have a competent and intelligent attendant to record the tempera- 
ture, pulse and respiration every hour, to observe changes in the pa- 



100 TREATISE ON FRACTURES 

dent's condition, and to note the development of consciousness, coma, 
convulsions, paralyses, etc. The head should be shaved, an ice-cap 
applied and the patient given a cathartic, if possible; if he is uncon- 
scious, the lower lxnvel should be emptied by a cleansing enema and 
the bladder evacuated by catheter. In cases in which there is a pos- 
sibility of infection of the meninges occurring, the patient should be 
given 10-20 grains of hexamethylenamine three times a day. This 
drug should be continued for a period of three to four weeks, or until 
all danger of meningeal infection has passed. This medication follows 
the advice of Crowe and Cushing as a prophylactic measure against 
the development of infection of the meninges. They believe that 
hexamethylenamine given by the mouth appears in the cerebrospinal 
fluid in from thirty minutes to one hour after ingestion of the drug, 
and that its use exercises a decidedly inhibitory effect on the develop- 
ment and extension of meningeal infections. 

Wben the temperature remains subnormal for a time, the patient 
should lie with the head low and be surrounded with hot- water bottles 
and covered with blankets. In severe cases of shock, with subnormal 
temperature and low blood-pressure, it may be advisable to bandage the 
extremities and overcome the vasomotor depression by hypodermic in- 
jection of atropin. 1/100 grain ; by the intravenous injection of normal 
saline solution, or by stimulating enemata such as the following: salt 
solution 2 ounces, black coffee 2 ounces, brandy 1 ounce, tincture of 
digitalis I drachm, to be repeated in two hours if necessary. This 
treatment is advisable only in those extreme cases in which marked 
shock is present, because there is considerable risk in over-stimulation 
should there be laceration of intracranial vessels. It must be remem- 
bered, however, that patients in marked shock will die. and that very 
quickly, unless stimulated. 

In case- where the shock has been overcome and there is a progres- 
sive rise in temperature, and in those in which there is a progressive 
rise in temperature from the beginning, not due to active stimulation, 
and in which all the symptoms point to compression without any 
localizing signs, the treatment should lie entirely different. Then, in- 
stead of stimulating the patient, the surgeon's efforts should be directed 
toward reducing intracranial pressure. There are several ways of 
reducing this pressure: venesection, lumbar puncture, and decompres- 
sion operations on the skull in the cerebellar or intermusculotemporal 
regions. 

\ 1 NESECTION. — The treatment of intracranial compression due to 
hemorrhage by venesection has advocates and opponents. Its use as 
a means of reducing arterial pressure is therefore not established, 
von Bergmann, Hill, and Rawling consider that it is of great value, 



FRACTURES OF THE CRANIUM 161 

while Falkenheim, Naunyn, and Cushing are not in favor of it, except 
early in a very few selected cases, in which there is an abundant re- 
serve on the part of the vasomotor centre. Our experience has shown 
that it has been of use when employed in early cases, but that in late 
cases in which the vasomotor centre is exhausted it is useless. The 
blood may be withdrawn from any of the superficial veins of the body, 
the safest and most readily accessible being the median basilic, ex- 
ternal jugular, and the long saphenous veins. About ten to thirty 
ounces may be withdrawn under aseptic precautions. The quantity 
should be governed by the fall of blood-pressure to nearly normal. 

Lumbar Puncture. — As a diagnostic procedure, lumbar puncture 
probably has its use; but as a means of relieving intracranial pressure 
it is doubtful whether it does good. It may lead to dangerous and 
fatal results by intracranial pressure forcing the medulla and the edge 
of the cerebellum into the foramen magnum, after the support of the 
cerebrospinal fluid has been removed by lumbar puncture. However, 
the procedure has many advocates. Quinn records seven cases of 
fracture of the skull " cured " by means of lumbar puncture. In one 
of the cases the procedure was performed eight times. 

Decompression. — Cerebellar decompression is rarely a justifiable 
procedure in cases of diffuse intracranial injuries, and the good results 
to be obtained by this procedure are questionable. The intermusculo- 
temporal decompression operation advised by Cushing has been fol- 
lowed by brilliant results, especially in the hands of its originator. The 
advantages claimed for this procedure are that it is done in the middle 
fossa — a region where most lesions at the base occur — exposure of the 
middle meningeal artery is obtained, approach to the region occupied 
by the temporosphenoidal lobe — where most frequent contusions of 
the brain occur — is gained, dependent drainage is obtained with ease, 
and the drainage so obtained occurs through the split temporal muscle 
rather than through the scalp alone. This position secures good drain- 
age and is not likely to be followed by hernia cerebri. 

Fractures of the Vault. — In closed fissured fractures of the vault 
without intracranial injury the treatment should consist of rest and 
observation. It is difficult to determine that such a fracture is present. 
Most fractures of the vault are, however, either depressed, comminuted 
or compound, and here the treatment will differ. Operative interven- 
tion is advisable in all depressed fractures, punctured fractures, frac- 
tures complicated by intracranial hemorrhage, and as an exploratory 
measure when the condition of the bone is uncertain. Fractures as- 
sociated with only a mild degree of concussion require no active treat- 
ment beyond rest in bed and treating the symptoms of concussion as 
they arise, unless there is reason, from, the character of the trauma, to 
11 



162 TREATISE OX FRACTURES 

think that the inner table may be splintered. When there is a marked 
degree of concussion present, more active measures are required. 
With subnormal temperature, stimulation is indicated until reaction 
occurs. When associated with suspected cerebral contusion, the pa- 
tient should be kept in a darkened room, and sedatives are required. 
In addition, some moderate form of restraint may be wise. An ice- 
cap should be applied to the head, and morphine and atropine are 
indicated until the restlessness disappears. As cerebral contusion. 
is associated with more or less laceration of the brain substance, the 
patient should be under a long period of observation and restrained 
from too great activity, physical and mental. 

In depressed or comminuted fracture of the vault, with or without 
symptoms of compression, and in obscure fissured fracture, operative 
interference is advisable. By this means alone is one able to elevate 
depressed fragments, determine the presence of depression of frag- 
ments of the inner table alone, and also prevent many of the remote 
effects of brain injury. 

Operative Procedures for Fracture of the Vault. — -The scalp 
should be shaved, thoroughly washed with soap and water, alcohol and 
ether. A rubber band or scalp tourniquet is applied around the head 
above the ears and a scalp flap made according to the location and 
extent of comminution or depression of fragments. The pericranium 
is stripped away from the involved area, and often it is possible with a 
suitable bone elevator to lift up depressed or comminuted fragments. 
If this is not possible, a trephine opening may be made at the edge of 
depression and the fragments elevated after the removal of a button 
of bone (Figs. 161-164). The centre pin of the trephine should be 
placed on solid bone, and the crown of the trephine should overlap the 
margin of the fracture so as to permit the elevator to be used. Ex- 
posure of the dura should be carefully made, lacerations should be 
carefully investigated, and examination made for the presence of frag- 
ments in the brain substance and for extra- or subdural hemorrhage. 
The dura should either be incised or the laceration in the dura, if one is 
present, should be enlarged, when the brain is believed to be damaged. 
Otherwise the dura need not be disturbed. Detached bone fragments 
should not be replaced unless the brain is thought to be uninjured and 
the wound is sterile. After trephining or other operation on the 
cranium for fracture, the fragments may at times be replaced, if 
sterile or sterilized, in order to get a bony closure of the opening in- 
stead of the fibrous or fibrocartilaginous membrane which otherwise is 
provided by nature. Sometimes a thin shaving of bone may be cut 
from the margin of the opening and laid over the hole like a lid' These 
methods may be left for a secondary operation if postponement is 



FRACTURES OF THE CRANIUM 



163 



considered wiser than immediate plastic closure. After all fragments 
in the brain substance have been removed and hemorrhage controlled, 




-Method of trephining with the Hudson instruments. After exposure of the site of fracture 
the skull may be opened at the site of depression. 




Fig. 162. — Hudson's trephine bits, showing the use of the spiral perforator, the spiral follower, and 
the enlarging burr. (After Rawling.) 



the -wound of the dura should be closed with interrupted sutures of 
fine catgut, and the skin flap closed with interrupted sutures of silk- 
worm gfut without draina.se. 



164 



TREATISE ON FRACTURES 




Fig. 163. — Removing a button of bone at the edge of the depressed fracture with the hand 
trephine. The Roberts aseptic conical trephine and other perforating methods are available. Note use 
of scalp tourniquet. 




1 '"■- 164.— H of 1 ">tic after trephine opening has been made. 



FRACTURES OF THE CRANIUM 



165 



In open compound fractures the scalp should be shaved, thoroughly 
scrubbed with soap and water, alcohol and ether. The edges of the 
wound should then be trimmed with a pair of scissors and the entire 
wound irrigated with a 2 per cent, solution of iodine in alcohol. The 
wound should then be enlarged for inspection of the seat of fracture, 
and the same general lines of treatment followed as in simple frac- 
tures. Drainage will depend upon the character of the wound, the 
general condition of the patient, and the degree of contamination. 
When in doubt do not drain. 

Fractures of the Base of the Skull. — In simple fractures of the 




base of the skull without intracranial complications, the treatment 
should be symptomatic. The prognosis and treatment depend entirely 
upon the kind and degree of the accompanying lesions. The same gen- 
eral principles given above should be carried out. Of especial gravity 
are hemorrhage, with the escape of cerebrospinal fluid or brain tissue 
from the nose, mouth, or ear, the possibility of infection being very 
great; and intracranial hemorrhage producing compression of the 
brain. In hemorrhage from the nose, mouth, or ears, or when there is 
discharge of cerebrospinal fluid from these orifices, syringing of the 
nose, mouth, or ears is strongly contraindicated. The nose or ears 
should be kept clean by means of swab of cotton soaked in boric acid 



166 TREATISE ON FRACTURES 

solution. Under no condition should these cavities be packed with 
gauze. The syringing is liable to force organisms from these cavities 
to the meninges and thereby produce infection, and packing of these 
orifices is unwise because the escape of blood lessens the degree of 
compression of the brain, especially when hemorrhage is profuse. 

Intracranial Hemorrhage. — As middle meningeal hemorrhage usu- 
ally produces compression of the brain and unless relieved causes 
eventually coma and death, the expectant form of treatment is hazard- 
ous and should not be followed. So soon as symptoms of this form 
of hemorrhage are presented, immediate operation is indicated. 
Various methods of approach have been suggested. Perhaps the one 
most universally followed is that of Kronlein. The principal thing to 
be borne in mind is the location of the middle meningeal artery. The 
main artery runs across the middle of the temporal fossa; it divides 
into its branches at the pterion, which is about two fingers' breadth 
above the zygoma and a thumb's breadth behind the vertical (spheno- 
frontal) process of the malar bone (Vogt's rule). Vogt advises plac- 
ing the point of the trephine at the insertion of these two points. 
Kronlein describes an anterior and a posterior point of election for 
trephining as follows ( Fig. 154) : A line is drawn through the supra- 
orbital ridge backward, parallel with the horizontal line of the skull, 
which is a line through the external auditory opening and inferior 
orbital ridge. Both points of election for trephining should be on this 
line (Fig. 165), the anterior one 3 or 4 cm. behind the zygomatic 
process of the frontal bone, the posterior one at the intersection of 
the given line with a vertical line passing immediately behind the 
mastoid process. Circumscribed hematoma of the fronto-temporal 
and temporoparietal regions may be reached through the anterior 
opening and the parieto-occipital variety of blood clot through the 
posterior opening. Krause advises exploration through an osteoplastic 
flap similar to the one he uses for the Gasserian ganglion excision. 
Cushing recommends an approach by means of the intermusculotem- 
poral operation. \Yhichever method of approach is used, the opening 
should be enlarged (Fig. 166) with craniectomy forceps, after remov- 
ing the button of bone, until sufficient exposure is obtained. The 
source of the extravasation can readily be determined by removal of 
the clot with a flat spoon and irrigation of the cavity with salt solution. 
The bleeding point may be secured and the hemorrhage checked by one 
of the following methods : by ligature, on both sides of the bleeding 
point ; by torsion of the vessel ; by gauze plugging; by occlusion of the 
artery by crushing the bony groove in which the vessel lies ; by plugging 
the foramen spinosum with a bone or wooden plugs or paraffin; by 
ligature of the common or external carotid arteries. 



FRACTURES OF THE CRANIUM 



167 



dishing considers that 90 per cent, of cases of meningeal hemor- 
rhage prove fatal, if unrelieved surgically, 60 per cent, of them dying 
within the first twenty-four hours. Of the cases operated upon 67 per 
cent, recovered. YViesmann states that of 143 cases treated under the 
expectant treatment, 131 died and 12 recovered. Of 167 fatal cases 
not less than 60, more than one-third, died during the first twenty- 
four hours. 

The cause of death in those dying within twenty-four hours is 
probably paralysis of the heart and respiration from pressure on their 
centres in the medulla. In patients living several days or weeks and 
then dying, the cause of death is probably a generalized oedema. 




56. — Showing method of enlarging trephining openings at points of election to reach the anterior 
and posterior branches of the middle meningeal artery. (Modified after Rawling.) 



von Bergmann reports no operative cases with 74 recoveries and 36 
deaths, a mortality of 32.27 per cent. ; Blake, 42 cases submitted to 
operation with only 3 deaths, and Duchain, 27 operative cases with 
only 6 deaths. 

Hemorrhage from rupture of intracranial sinuses demands imme- 
diate operation. As a general rule these injuries are associated with 
either open, depressed, or punctured fractures of the skull, and a 
diffuse subdural hemorrhage results. In such instances, the wound, if 
the fracture is compound, should be enlarged under thorough asepsis ; 
and if a closed fracture is present the method of procedure should be 
to expose the bone by an incision. Depressed fragments should be 



16S 



TREATISE OX FRACTURE 




Fie. 167- — Trephine opening for subdural hemorrhage. Opening h 
trephine. iModined after Rawling.) 



en made with a Hud=on 




FRACTURES OF THE CRANIUM 



169 




_ Fig. 169. — After washing out subdural clot, a rubber tube drain is inserted and the dura closed 
by interrupted sutures about the drain. The end of the latter is carried through the temporal fascia 
and skin. (Modified after Rawling). 




Fig. 170. — Shows suture of the temporal muscle by interrupted sutures of catgut, and partial 
closure of the temporal fascia. The fascia is sutured and the skin closed with interrupted sutures. 
(Modified after Rawling.) 



170 TREATISE ON FRACTURES 

elevated, detached fragments removed, the opening in the cranium 
enlarged if necessary with craniectomy forceps, so that sufficient ex- 
posure of the involved sinus be obtained for working purposes. If 
possible, the laceration of the sinus is to be closed by interrupted 
sutures of fine silk, or by a lateral ligature ; or both of the bleeding 
ends of the sinus should be ligated with silk. If this is impossible, the 
hemorrhage may generally be controlled by compressing the sinus with 
sterile gauze packing; the wound in the scalp is to be closed except at 
the point of drainage. Luys reports 42 cases of injury to the sinuses, 
of which 20 were followed by good results from operative interference. 

Hemorrhage from the cranial portion of the internal carotid ar- 
tery is followed by death so quickly that operative intervention is 
generally impossible. 

In subdural localized hemorrhage, which is generally from injury 
to the pia-arachnoid vessels and laceration of the cortex, the symptoms 
of hemorrhage and the development of pressure symptoms are delayed 
from several days to a week or more. Upon the development of 
localizing symptoms of pressure, operative interference is demanded. 
Under aseptic precautions, and with a scalp tourniquet, a flap is raised, 
the cranium trephined, and the dura exposed. The membrane will 
be found to be blue, nonpulsatile, and bulging. The dura should be 
incised, the clot removed with a spoon, and the cavity cleansed by 
irrigation with warm normal salt solution. Afterwards the opening 
in the dura should be closed with catgut or silk suture, excepting at 
the lower portion, where a rubber tissue drain should be placed and 
the scalp wound sutured, except at the point of drainage. The drain 
should be removed at the end of forty-eight hours (Figs. 167-170). 

Bowen, to whom we are indebted for a most complete monograph 
on this subject, reports 72 cases, as follows: 

Class A. — Subdural hemorrhage without serious injury to brain: 
36 cases; 22 recovered after operation; 14 died — 11 without and 3 
after operation. 

Class B. — Subdural hemorrhage with serious brain injury: 36 
6 recovered after operation; 30 died — 10 without and 20 after 
operation. 

Summary of Treatment of Cranial Fractures 

Closed fissured fractures 1. No evident depression, no brain 

symptoms No operation 

2. No evident depression, with brain 

symptoms Incise scalp and 

open skull 

3. \\ ith evident depression, no brain 

symptoms Incise and probably 

open skull 

4. With evident depression, with 

brain symptoms Incise and open skull 



FRACTURES OF THE CRANIUM 171 

•Closed comminuted fractures. 5. No evident depression, no brain 

symptoms Incise scalp and 

probably open skull 

6. No evident depression, with brain 

symptoms Inciseand openskull 

7. With evident depression, no brain 

symptoms Incise and open skull 

8. With evident depression, with 

brain symptoms Incise and open skull 

Open fissured fractures 9. No evident depression, no brain 

symptoms No operation but 

treat wound 

10. No evident depression, with brain 

symptoms Open skull 

11. Wi th evident depression , no brain 

symptoms Open skull 

12. With evident depression, with 

brain symptoms Open skull 

Open comminuted fractures. 13. No evident depression, no brain 

symptoms Probably open skull 

1 4. No evident depression, with brain 

symptoms Open skull 

15. With evident depression, no brain 

symptoms Open skull 

16. With evident depression, with 

brain symptoms Open skull 

Punctured and gunshot frac- 
tures 17. In all cases Open skull 

Treat all cases as incipient encephalitis, and if primary operation decided upon 
as necessary, do not delay more than a few hours. 



CHAPTER IV 



FRACTURES OF THE BOXES OF THE FACE 
Anatomy. — Anatomically the bones of the face comprise the two 
nasal bones, the two lachrymal bones, one vomer, the two inferior tur- 
binated bones, the two superior maxilla?, the two palate bones, the 
two malar, one inferior maxilla, and one hyoid bone. On account of 
the close relation with each other individual fractures of facial bones 
are generally limited to the nasal, the superior maxilla, the malar, and 
the inferior maxilla. Fractures involving the other facial bones are 
either in conjunction with the bones of the cranium, or are associated 
with fractures of the nasal or superior maxilla. 

Fractures of the bones of the face are usually caused by severe 
direct violence and the result is generally fracture of several bones. 
This is particularly seen in fractures of the nasal bones and of the 

Pig. 171. Fig. 172. Fig. 173. 





—Diagram of side of nose showing relations of bones and cartilages. 
FIG. 172. — Diagram of the bones and cartilages of the nose, anterior view. 
Fig. 173. — Diagram of the septum of the nose. From Roberts's Surgery of Face. 

superior maxillary. In fracture of the nasal bone the nasal spine of 
the frontal, the nasal process of the superior maxillary, the ethmoid 
and the vomer may also be involved. In fracture of the superior 
maxillary, the malar, the nasal, lachrymal, and palate bones may also 
be fractured. Owing to the great vascularity of the part and the char- 
acter of the hone, union generally takes place rapidly with the forma- 
tion of a small amount of callus, and deformities are frequent unless 
early reduction of the fragments is performed. 

Fractures of the Nasal Bones. 
Anatomy.— The nasal hones (Figs. 1 ; 1 [73) are two flattened 

triangular-shaped hours which unite in the median line to form the 
bridge of the nose. They articulate above with the nasal portion of 
the frontal with the frontal process of the maxillary. In addition 
there are five nasal cartilages, two upper and two lower lateral and the 
triangular nasal septum. 

Fractures of the nasal bones may involve the nasal processes of 



FRACTURES OF THE BONES OF THE FACE 



173 




Fig. 174. — (.4) Fracture of nasal bones and nasal process of left maxilla. Both nasal bones were 
fractured near lower end and a small piece was detached from the anterior margin of the left maxilia. 
Great deflection of front part of ethmoid and middle of vomer to left. (B) Fracture of nasal bones and 
nasal process of right maxilla. Fracture of both nasal bones transversely at middle. Union with 
deformity, consisting of deflection of nasal bones to the left. (C) Fracture and dislocation of nasal 
bones. Transverse fracture of both nasal bones near the middle. Union without much displacement. 




Fl^s. 17.S and 176. — Photographs showing depressed healed fractures of right frontal, malar, 
superior maxilla, and nasal bones. Injured by a fall of coal while working in the coal mines three years 
previously. Lateral and anterior views. 



174 TREATISE ON FRACTURES 

the frontal and superior maxillary, the cartilaginous septum, the lateral 
cartilages of the nose, the perpendicular plate of the ethmoid, the 
vomer and lachrymal hones. Fractures of the nose are generally com- 
minuted, often compound through a tear of the nasal mucous mem- 
brane. 

The cartilages and bones, forming the framework of the nose, are 
united with each other and with their neighbors by sutures at which 
normally there is no motion. If dislocation occur between a bone of 
the nose and an adjoining bone or cartilage, the rupture of the suture 
line is similar to a fracture of bony tissue. 

Fractures of the nasal bones (Figs. 174-179) are due to direct 
violence. The displacement of fragments is primarily due to the force 
and direction of the fracturing force, and secondary displacement may 
be due to handling, blowing of the 
nose, and sneezing. Displacement is 
never produced or made recurrent by 
attached muscles. 

The most common forms of fract- 
ure are : A transverse lesion near the 
middle in which the lower fragment is 
driven backwards at an angle with the 
upper fragment. In this fracture the 
quadrangular cartilage may receive the 
force of the blow, and be drawn back- 
ward with the lower portion of the 
nasal bone which has been broken off. 
fig. 177.— Photograph showing profile of As a result the cartilage may be fract- 

oase of fracture of nasal bom :s with depression 11 i- i , j r 

of fragments. Fracture produced by direct urecl, bent, or dislocated from its at- 

violence while turning a handspring. , , , « . . . , . 

tachment to the upper border of the 
vomer; or its lower anterior angle may be torn loose from the mem- 
branous portion of the septum, or from its connection with the 
maxillary bones at the anterior end of the vomer. 

Fractures in which the comminuted fragments are driven directly 
backward so as to He behind the nasal processes of the maxillary 
bones. Instead of a fracture, or coincident with the fracture, a luxa- 
tion may occur between the nasal bone and the nasal process of the 
maxilla; or the nasal hones, while remaining attached to each other in 
the medium line, may be dislocated and occupy a somewhat similar 
relation to one or both maxillae. 

Fractures produced by a blow upon the side of the nose. In these 
cases the nasal hones may he luxated together, the outer edge of the 
nasal hone on the side of the injury being driven under the border of 
the maxillary process, while the outer edge of the other nasal bone is 
displaced on top of the maxillary process. In severe injuries the nasal 




FRACTURES OF THE BONES OF THE FACE 



175 



processes of the superior maxillary bone may be fractured as well as 
the nasal bones themselves. 

The frontal bone and the horizontal plate of the ethmoid bone may 
be involved in severe fractures of the nose in such a way that the frag- 
ments are driven into the cranial cavity. Impaction is usual in these 
cases. The frontal sinus is very likely to be opened, and meningitis 
may develop as a result of infection. The cribriform or horizontal 
plate of the ethmoid is not likely to be fractured when the force injur- 
ing the nose spends its strength upon the lower third of the nasal 
bones. It is the perpendicular plate of the ethmoid bone that then 
bears the brunt of the injury. 




Fig. 178. — Skull; old fracture of nasal bones and left zygoma. The nasal bones were fractured in 
the middle and have united with decided depression of the nose. The nasal septum is deviated strongly 
to the left. The left zygoma was fractured at the summit of the arch but has united. (Mutter Museum, 
No. 1169.09) 

Fig. 179. — Skull; fracture of the nasal bones; union. The bones are fractured transversely at 
the middle and have united with a decided deflection to the left. The vomer is extremely displaced to 
he right. (Mutter Museum, No. 1169.06.) 



Fractures from force applied to the upper border of the nasal 
bridge generally involve the ethmoid, while in those cases in which the 
force is received upon the lower part of the nose the quadrangular 
cartilage of the septum and the vomer are most apt to be injured, the 
line of fracture is perhaps more frequently horizontal in its general 
direction than vertical, and a luxation of the cartilage from the vomer 
is more common than from the ethmoid. In many instances, however, 
the fracture is associated with dislocation of the cartilage from the 
vomer or the ethmoid bones, and may assume more or less the char- 
acter of a triangular fracture-dislocation. The fragments of the car- 
tilage or of bone and cartilage may over-ride, so that the line of the 



176 TREATISE ON FRACTURES 

bridge of the nose shows a marked depression in the region of the 
lateral cartilages. 

The lateral cartilages, which form the lower portion of the bridge 
of the nose, may be dislocated from the lower border of the nasal bones 
and from each other. 

Methods of Examination. — The rapid swelling which accompanies 
these fractures of the nose soon obscures deformity in its frame- 
work, and causes many fractures and luxations to be overlooked. 
Anaesthesia with nitrous oxide or ether should be employed, if a care- 
ful examination cannot be made without great pain. Local anaesthesia 
with novocaine and adrenalin may be sufficient. Reflected light from 
a head mirror is essential in all cases because persistent obstruction to 
respiration from unreduced septal injuries may lead to mouth breath- 
ing and its attendant sequelae. Saddle-nose, bent nose, twisted nose, 
and occlusion are frequent witnesses of unrecognized and untreated 
fractures of the nasal bones. 

Symptoms. — Rapid swelling of the soft parts, bleeding from the 
interior of the nose, deformity, external and internal crepitus when 
fragments are not impacted, and preternatural mobility of parts of the 
nose are the more important of the early symptoms of fractures. Of 
the later symptoms may be mentioned subconjunctival ecchymosis. sub- 
cutaneous hemorrhage in soft tissues of nose and cheeks, and em- 
physema of eyelids and cheeks, indicating involvement of the accessory 
sinuses in the lines of fracture. Epiphora or imperfect drainage of 
tears from the eye to the lower nasal meatus is presumptive evidence 
that the nasal duct has been obstructed by swelling of its lining mucous 
membrane, or by distortion of its bony wall by reason of associated 
fracture of the maxilla, or by complete laceration of the duct in asso- 
ciation with fracture. The external forms of deformity may consist 
in flattening or depression of the bridge of the nose, broadening of 
the nasal arch as well as flattening, and lateral deviation with or with- 
out angularity. Dislocation of the lateral cartilage from the lower 
margin of the nasal bone produces a hollow in the dorsum of the nose 
near the junction of the middle and lower thirds. Deviations of the 
cartilaginous and bony septum may accompany fracture of the nasal 
bones. One or both nostrils may be obstructed by an oblique position 
of a septal fragment. 

Diagnosis. — The diagnosis of fractures of the nasal bones may be 
made by careful examination, particularly through the anterior nares 
with the aid of a speculum and good light, eliciting some of the above 
symptoms. External deformity is generally present. Deviation of 
the nasal septum may or may not be present. The principal form of 
deviation of the septum seen in conjunction with fracture of the nasal 
bones is a lateral displacement of the tip. and the most common form 



FRACTURES OF THE BONES OF THE FACE 



177 



of fracture is a horizontal one producing a gutter-like deformity in a 
horizontal plane. A triangular fracture-dislocation may cause a 
V-shaped piece of the septum to be driven backwards with the point 
toward the pharynx. 

Complications. — The complications of nasal fractures are pro- 
longed suppuration in compound comminuted fractures, followed by 
abscess of the soft parts and periostitis, perichondritis of bone or 
cartilage ; involvement of the frontal sinus in the line of fracture, 
producing emphysema of the subcutaneous tissues; extension of the 




Fig. 180. — Mosher's method of reducing, with thumb and elevator, fracture dislocation of nasal 
bones, when right nasal bone over-rides maxillary process and left is depressed and caught under its 
fellow and under the left maxilla. 



line of fracture to the anterior fossa of the skull with accompanying 
osteocranial injury or meningitis ; involvement of the cartilaginous or 
bony septum resulting in marked deviation; involvement of the lach- 
rymal duct due to the line of fracture involving the nasal process of 
the superior maxilla with resulting epiphora. 

Prognosis. — Union generally takes place in two to two and a half 
weeks. 

Treatment. — It is essential that all recent fractures of the nasal 
bones be promptly and skilfully treated so that deformity from un- 
reduced or carelessly replaced tissues may be averted. Injuries which 
are insignificant, so far as danger to life is concerned, may leave dis- 
12 



178 



TREATISE OX FRACTURES 



tortions of the outline of the nose or obstructions to breathing of great 
importance. Cosmetic i lerefore and the necessity of having 

sal ventilation and breathing, especially in children. 
should stimulate medical attendants to give attention to nasal injuries. 
The proper devei I the accessor}- sinuses and the associated 

ir F the - ler parts of the face depend upon free nasal 

- 
Recent Fractures. — The character of the injury and the form of 
displacement are to be determined by palpation of the exterior with the 
by a rigid slender instrument within the nose for 
.r-pressure. Elevation and restoration of the depressed or dis- 
placed frag::.:/.- :' the sseous arch of the nose may best be accom- 
. : narrow steel instrument into the nostril. This 




■ — 



■ ■ • - - iped I 
and the overlapping ot" the V an the vomer. The- 
■ atim. 
- -I septal cartilage 

.orsum. the 



steel rod mu- n . _ the top of the space between 

the nasal bone, the ethmoid plate, and the nasal process of the maxilla. 
By thrusting upward under the nasal bone and by proper manipulation 
externally, the surgeon can generally mould the displaced fragments 
into pi; - lerable force may at times be necessary 

to separate impacted fragme 

septum may be restored after careful 
examination by r -ceps with flap-wide blades. The septum 

sped by the blade into each nostril, and the dis- 

place-', -ward and its posterior end tilted upward by 

depression of the ham!' rceps. These manipulations, com- 

bined with lateral rest re usually the line of the nasal 

bridge from forehead to the tip of the nose, and replace the obstructing 



FRACTURES OF THE BONES OF THE FACE 179 

fragment of cartilage or bone into the middle of the cavity of the nose. 
If some time has elapsed since the injury, so that partial union of the 
displaced fragments has occurred, strong lateral movements with the 
forceps will generally be necessary to break up the fibro-osseous union 
and permit reposition. 

The corrected position of the nasal bones, lateral cartilages, and 
septal structures is to be maintained by internal splints, by nasal pins, 
or by external pads attached to forehead bands. The last are seldom 
necessary and generally accomplish very little. There is usually little 
or no tendency to recurrence of displacement of fragment after proper 
reposition, unless the patient handles his nose or blows it violently. 
When such a tendency exists because of great comminution, the parts 
may be retained in place by filling the internasal space with gauze pack- 
ing, or preferably by tubular nasal splints. Occasionally pins may be 
used to hold fragments in position (Figs. 181 and 182). Their use, 
however, is not advocated, except in a few well-selected cases. Their 
disadvantages are the presence of an open wound and the resultant 
scar at the site of the pin-holes. These objections are, however, not 
serious, if the pins and punctures are made aseptic. 

Old Unreduced Fractures. — These cases call for osteotomy and 
re-fracture with readjustment. Division of cartilage and bone may be 
performed through small external incisions or through puncture 
wounds of the mucous membrane. After osteotomy and re-fracture 
have been performed and readjustment completed, the external wound 
may be closed with collodion dressings. Internasal splints should be 
used to maintain reduction. In saddle-back deformities of the nose 
due to fracture, the normal external contour may be gained by the 
use of subcutaneous injections of paraffin. This material is injected 
with a syringe having a piston driven by a screw attachment and needle 
of large calibre. It may be injected when in a fluid state from heat and 
moulded into a proper contour. The cooling causes solidification and 
the new nasal outline is permanent. 

Lateral deformities involving the cartilaginous and bony bridge are 
as a rule accompanied by deviations of the cartilaginous and bony 
septum with occlusion of one or both nostrils. In these cases the 
prominence of the septum should be removed through a submucous 
resection to a point a quarter of an inch from the top of the cartilagi- 
nous bridge. If the lateral cartilages are displaced, their position is 
corrected by intranasal operations. The nasal bones are then chiselled 
loose and returned to their normal position. In all these cases proper 
internal retentive apparatus should be used for at least four to seven 
days and the nasal cavities should be kept as clean as possible by 
douching. 



CHAPTER V 
FRACTURES OF THE MALAR BOXE 

Anatomy. — The malar bone has three surfaces, — the facial, the 
posterior, and the orbital, — and articulates with the frontal, sphenoid, 
and the temporal bones ; and has two processes, the f rontosphenoidal 
and the temporal. 

Surface Markings. — The malar bone forms the prominence on 
the cheek. Its external surface may be readily palpated, and where it 
extends backward can be felt the prominent zygomatic arch. Above 
this is situated the temporal fossa in which can be plainly felt the move- 
ment of the temporal muscle during mastication, and pulsation of the 
anterior branch of the temporal artery. 

Fractures of the malar bone are the result of direct violence — 
either from without, as that of a blow or a fall upon a blunt object, or 
from within, as in a fall upon a stick held within the mouth. Isolated 
fractures of the malar bone are rare. They are seen usually in con- 
junction with fractures of the superior maxilla or of the frontal bone. 
The severe forms are accompanied by cerebral concussion and occa- 
sionally by an extension of the line of fracture to the base of the skull. 
Fractures of the malar bone may involve the orbit or the antrum of 
Highmore. 

Methods of Examination. — This is best accomplished by having 
the patient seated upon a chair. The surgeon standing back of him 
palpates the malar bones with his two hands at the same time (Fig. 
[83 ). Any irregularities or depressions will be readily detected. The 
entire external surface, the inferior surface, the zygomatic process, 
the malar portion of the orbital margin, the frontal process, may be 
readily examined. 

Varieties of Fracture.— Fractures of the malar bone may involve 
the body or its processes. Those of the body are of various degrees, 
depending upon the direction and degree of the fracturing force (Figs. 
1X4,-111(1 [85). They form the greatest number of fractures of this bone. 
The external surface is crushed inward toward the maxillary sinus, 
and the fracture generally involves the superior maxilla. Fractures of 
the zygomatic arch ( Fig. 186) alone are rare, and are generally due 
to external direct violence, although they may result from force trans- 
mitted through a stick held in the mouth. The fragments are usually 
displaced in the direction of the fracturing force. The fragments may 
be driven inward and so produce pressure upon the coronoid process 
of the interior maxilla or the tendons of the temporal muscle, making 
movements of the lower jaw difficult or impossible. Separation of the 



FRACTURES OF THE MALAR BONE 



181 



entire malar bone from the remaining portion of the facial skeleton 
occurs, but true suture disjunction is very rare. In these cases the 
lines of fracture are near the suture lines and generally involve the 




Fig. 183. — Method of palpation of malar bones. Any irregula 
sions will be readily detected. 




FlG. 184. — Lower half of skull. Fracture of the left malar; union. The bone was fractured close 
to its junction with the superior maxillary. Union has occurred, incomplete inferiorly and marked by a 
spicule at the margin of the orbit, pointing toward the nose. (Mutter Museum. No. 1169.08.) 

Fig. 185. — Skull; old fracture of the nasal and left malar bones. The fracture occurred close to 
the upper border of the nasal bones and from the orbital margin of the malar toward the inferior angle. 
The deformity of the nasal fracture consists of a decided depression on the left side in which the internal 
angular process of the left frontal has shared. There is a fissure in the malar and slight exostosis on the 
orbital margin. From a sabre cut. (Mutter Museum, No. 1160. 10.) 



processes of the frontal, temporal, and superior maxillary bones, com- 
bined with fracture of the zygoma. Fracture with dislocation and dis- 
placement of the entire bone into the maxillary sinus is possible. For 



182 TREATISE ON FRACTURES 

this rare injury the fracturing force must be great ; and the entire bone, 
together with the zygoma, may be forced into the maxillary sinus. 
Fractures with dislocation of the bone into the orbit or into the spheno- 
maxillary fossa have occurred. The last three varieties of fracture 
are rare, are the result of great violence, are generally accompanied by 
fractures of other of the facial bones, and the line of fracture fre- 
quently involves the base of the skull. 

Symptoms. — These injuries are recognized by the deformity, the 
irregularity of outline, and crepitus. There is flattening of the cheek 
to the outside and l>elow the orbit. In addition there is generally sub- 
conjunctival ecchymosis and occasionally protrusion of the eyeball. 
Mobility as bad as crepitus may 
occasionally be discovered. Of the 
rarer symptoms there may be areas 
of anaesthesia corresponding to the 
distribution of the superior maxil- 
lary nerve, which may be injured 
when the line of fracture extends 
into the floor of the orbit. The 
bleeding from the nose, due to lacer- 
ation of the mucous membrane of 
the antrum, difficulty in movements 
of the lower jaw, due to pressure of 
fragments of the zygomatic arch 
upon the masseter muscle and coro- 
noid process of the inferior maxilla, 
or fracture of the latter in conjunc- 
tion with fracture of the zygomatic 
arch are occasional evidences of the 
fracture. 




Fie. 1 86.— Skull; fracture of left malar. -p.- . „, ,. 

The left malar was fractured obliquely, down- UiagnOSlS. [ he diagTlOSlS Of 

wards and forwards, near the zygoma. Union r r i , , 

has occurred with slight depressions of the zvgo- traCtltre OI tile malar bone mav best 

matic arch. (Mutter Museum, No. 1160.20.) 1 , ^ • , . , , . „".. 

be determined!)}- deformity. Mobility 
and crepitus arc rare. Deformity is generally masked by swelling. If 
one. however, carefully palpate the two sides of the face at the same 
time, the change in facial contour may be discovered; and if in addi- 
tion to slight flattening of the body of the malar bone there is subcon- 
junctival ecchymosis, bleeding from the nose, or localized swelling, 
one may pretty safely conclude that there is a fracture. Radiography 
may confirm the diagnosis. Fracture of the zygoma may be readily 
recognized by the presence of swelling of the soft parts, the evident 
depression of the arch, and the limitation of motion of the lower jaw. 
Complications.— Of these the most important are injury to the 
superior maxillary nerve, contusion or destruction of the bulb or optic 



FRACTURES OF THE MALAR BONE 



183 



nerve, seen in extensive dislocations of the entire malar bone into the 
orbit, and fracture of the anterior cerebral fossa in extensive com- 
municating fractures. 

Prognosis. — This is generally good unless there is laceration of 
the superior maxillary or optic nerves or an extension of the fracture 
lines into the base of the skull. These fractures heal very rapidly with 
the formation of little callus, hence reposition of fragments should be 
made as soon as possible. Otherwise varying degrees of flattening of 
the face over the malar bone and zygomatic arch will remain as perma- 
nent disfigurements. 




-Lothrop's method of reduction of depressed and coram: 

superior maxilla. 
-Matas's method of reduction of a. depressed fracture of the zygomatic arch. (S 



ted fractures of the malar and 
Fig. 187). 



Treatment. — In many cases it is difficult to obtain complete re- 
placement of fragments. In fracture of the zygoma it is possible to 
elevate depressed fragments by means of an incision through the skin 
and direct elevation. In fractures of the body of the bone this method 
is not so feasible, as it may be impossible to maintain reduction of the 
fragments. Depression of the body of the bone down into the 
antrum of Highmore may be corrected by the method devised by 
Hamilton and also by Howard A. Lothrop (Pig. 187). This consists 
in making an incision through the mucous membrane of the canine 
fossa of the superior maxilla, breaking through into the antrum with 



184 TREATISE ON FRACTURES 

a sharp chisel, and elevating the depressed fragments by means of a 
curved steel instrument. A 21 F. urethral sound is ideal. After thor- 
ough elevation, packing the antrum with a strip of gauze is a wise 
procedure. This is left in place for five days; then the antrum is 
irrigated with warm boric acid solution for several days. After re- 
moving the gauze it will be found that sufficient union has taken place 
to hold the fragments in their corrected position. 

Sometimes the body of the fractured bone may be drawn forward 
into position by making small incisions above and below and grasping 
its edges by a pair of forceps shaped like the tongs used for carrying- 
blocks of ice. In old fractures of the malar bone with deformity, it is 
generally impossible to correct the depression except by subcutaneous 
injection of paraffin, or the transplantation of a ball of fatty tissue, 
which may be cut from the abdominal wall. 

Depressed fractures of the zygomatic arch may be reduced by the 
method of Matas (Fig. 188), which consists in introducing a hook 
through a small punctured wound below the arch and pulling the dis- 
placed fragment outward, or by an elevator introduced through a 
quarter-inch incision above the arch. 



CHAPTER VI 

FRACTURES OF THE SUPERIOR MAXILLA 

Anatomy. — The superior maxilla occupies the middle of the face, 
and helps to form the floor of the orbit, the roof of the mouth, and a 
considerable portion of the nasal fossse. It consists of a body and four 
processes : the frontal or nasal process, the zygomatic process, the 
palatine process, and the alveolar process. The body contains a large 
sinus, the maxillary sinus or antrum of Highmore, and has four sur- 
faces : the anterior, the orbital, the infratemporal, and the nasal. 

Surface Markings. — The anterior surface can be readily palpated 
as well as the palatine process and nasal surface. 

Fractures of the superior maxilla are frequently accompanied by 
fracture of the malar, nasal, lachrymal, or palate bones. The injury is 
rare and apt to be due to violence acting directly upon the bone, such 
as a blow, a fall upon the face, the kick of a horse, the extraction of 
teeth, and gunshot wounds. This method of production is the cause 
of the injury being frequently an open fracture. Indirect violence, 
through transmitted force as seen in fractures of the malar or nasal 
bones, may occasionally cause the superior maxilla to be broken. 

Methods of Examination. — The outline of the body and the various 
processes of the superior maxilla may be readily palpated. Its fracture 
can be readily determined, especially if an anaesthetic is used. 

Fractures of the superior maxilla may be classified as follows : 

Partial fracture of the alveolar process, the palatine vault, the nasal 
process, the maxillary sinus walls. 

Gross fractures are intermaxillary separation or disjunction, hori- 
zontal fractures of three types, separation of the entire alveolar process, 
double horizontal fracture of A. Guerin, and craniofacial disjunction. 

Perforating fractures, generally of the hard palate and floor of the 
orbit, the result of gunshot and penetrating wounds through the mouth. 

Fractures of the body, frequently comminuted, may involve the 
antrum of Highmore. They are also seen in conjunction with frac- 
tures of the malar or nasal bones. 

Fractures of the alveolar process are due to direct violence, as a 
blow or a fall upon the face, or to the unskilful extraction of teeth. 

Definite fracture lines according to the direction of the force have 
been ascertained in fractures of the superior maxilla by the recent 
investigations of A. Guerin: A transverse fracture runs backward 
into the pterygoid process almost i cm. below the malar bone on both 
sides and is the result of a severe blow from before backward below 
the nostrils in the median line or somewhat to the side. There may 

185 



18(3 TREATISE ON FRACTURES 

be entire displacement of the vault of the mouth with the alveolar 
processes posteriorly. The pterygoid processes are fractured at the 
level of the lower border of the pterygoid maxillary fissure. Fissur- 
ing of the palate bones from before backward may also take place. If 
the fracturing force is lateral and corresponds to the level of the palate, 
the above form of fracture results, and if the direction of the force is 
sagittal there is always a fracture of the pterygoid processes in addi- 
tion. \\ 'hen the fracturing force is lateral and oblique from above 
downward, the alveolar process is detached and also a portion of the 
body of the bone, depending upon the level of the fracturing force. 
"When the fracturing force is from below upward there may be fissures 
surrounding the malar bone ; and when the force is severe and bilateral 
there may be detachment of the entire median portion of the bony 
face, with extension of the fracture lines from the nasal apertures 
toward the orbits. Fissure fractures of the palate may also be present. 
A severe blow received from a broad surface acting upon the superior 
maxillary and malar bones may cause complete detachment of the facial 
bones from. the skull proper. This form of injury has been observed 
by Dr. Kelly in the case of an elevator accident. 

Symptoms. — The symptoms of fracture of the superior maxilla are 
in great degree dependent upon severity of injury. The principal 
symptoms are swelling, ecchymoses, asymmetry, crepitus and mobility 
of fragments. Man\- of these fractures may be compound into the nasal 
or oral cavities and communicate with the antrum of Highmore. Lac- 
erations of tbe mucous membrane of the latter may lead to emphysema 
of subcutaneous tissues. A careful inspection of the nasal and oral cav- 
ities should be made. At times a general anaesthetic will be necessary. 

Jn severe injuries the lines of fracture may extend into the base of 
the skull and there may be coincident injury to the intracranial contents. 

Complications. — Compression or laceration of the lachrymal duct, 
injury to the superior maxillary nerve, injury to the orbital contents, 
meningitis, hemorrhage, periostitis, necrosis of bone, are occasional 
complications of maxillary fracture. 

Diagnosis.— Examination of the surface of the face, the interior 
of the nose and mouth will disclose the nature of the fracture. If 
there is no displacement of fragments, examination may detect the 
source of the hemorrhage and the possible tear in the mucous mem- 
brane. Fractures of the body will show some irregularity of surface 
contour. Fractures of the alveolar process will be determined by 
crepitus, mobility, and irregularity in the outline of the teeth. Em- 
physema of the subcutaneous tissues points to injury involving the 
antrum. In severe injuries, the diagnosis is evident from the asym- 
metry, crepitus and mobility of the fragments, although it may be 
impossible to determine the full extent of the line of fracture, or the 



FRACTURES OF THE SUPERIOR MAXILLA 187 

existence of involvement of the base of the skull unless symptoms of 
intracranial injury develop. 

Prognosis. — In uncomplicated cases union of the fragments gen- 
erally takes place in three or four weeks without the formation of 
much callus and with little deformity. Severe neuralgia may persist 
for a long time from involvement of branches of the superior maxil- 
lary nerve in the callus, and epiphora may persist due to obliteration 
of the lachrymal duct. Necrosis of bone is rare because of the abun- 
dant blood supply, and even portions that are detached may unite. On 
this account all portions of bone necessary for the contour of the face 
and alveolar process should be preserved if possible. Displacement of 
fragments, unless it be extreme, is seldom noticeable after healing 
takes place, unless the nasal bones are also fractured, in which event 
deformity of the nose may be permanent. 

Treatment. — In treatment of these fractures loose teeth should be 
left in place, as they frequently become permanently fixed again. Many 
disjunctions are readily reduced but difficult to keep in place ; union gen- 
erally results with a certain degree of deformity. This may be prevented 
in some cases by cutting down of fracture and suturing fragments with 
chromicized catgut, or using nails or screws for direct fixation. 

Loose fragments of bone should not be removed primarily because 
repair may take place without necrosis. In all open fractures into the 
mouth, nose, or maxillary sinus, thorough cleanliness should be ob- 
served. Frequent douching of the nose is then desirable, and some 
form of mild antiseptic solution, as a gargle should be used. Tartar 
should be removed from the teeth, which should be kept as clean as 
possible. In some fractures retention of the fragments may be secured 
after reduction by the use of interdental splints of vulcanite or metal. 
Very often it is possible to maintain reduction by means of the Angle, 
Hammond or Gunning splint. Several other forms of retention ap- 
paratus, notably that of Goffre and Grafe, have in addition to a splint 
surrounding the upper jaw a metal attachment running to a hood over 
the head. This apparatus is hard to keep in place, and unless great 
care is maintained is easily displaced and may cause the patient marked 
discomfort. "When possible these patients should be placed in the hands 
of a skilled oral or dental surgeon, who is able to apply the proper 
form of interdental splint. During the three to four weeks that 
closure of the mouth is required, liquid food is introduced through the 
crevices between the teeth, or by a tube passed between the alveolar 
arch and the cheek back to the last molar tooth. 

"When the fracture involves anterior and lateral portions of the 
antrum of Highmore, an accompanying fracture of malar bone is pres- 
ent with depression of the superior maxillary and malar bones inward. 
Reduction is best accomplished by the method of Lothrop (Fig. 187). 



CHAPTER VII 

FRACTURES OF THE MAXDIBLE 
Anatomy. — The inferior maxilla, or mandible (Fig. 189), is the 
only bone of the skull connected with the others by a joint. It is com- 
posed of a body and two rami. The body is horseshoe in shape, from 
the posterior extremities of which ascend the two rami. In fact the 
bene may be considered as a union of two symmetrical halves, which 
form the framework of the lower part of the face. The body has a 
base, or inferior portion, and an alveolar portion containing the alveo- 
lar border. On the anterior external surface is the mental protuber- 
ance, and at each side of this near the base the mental tubercles. Above 
and external to the mental tubercles are the mental foramina. 

The external surface also presents an oblique line extending down- 
ward from the coronoid process of each ramus. The internal surface 



Coronoid process 



Condyloid process 




Mental foramen 



Fig. 189. — Mandible, outer aspect. (Piersol's Anatomy.) 



of the body presents the digastric fossa, the mental spine, the mylo- 
hyoid line, the mylohyoid groove and the mandibular foramina. Ex- 
tending upward from the posterior extremities of the body are the 
rami, at the beginning of which on each side is the angle of the in- 
ferior maxilla. At the summit of the rami are the condyloid process. 
the notch of the mandible, and the coronoid process. 

Surface Markings.— The entire inferior maxilla can be readily 
palpated externally, and internally also by a finger in the mouth. The 
prominent anterior part, the symphysis mentis, the ridges or alveolar 
jugae, the edge of the masseter muscles, the angle, and the coronoid 
process may be felt, and the examiner can fairly well outline the 
tempero-maxillary articulation. 

Statistics.— Fractures of the inferior maxilla are more frequent 
than of the superior maxilla. They are rare in childhood and old age.. 



FRACTURES OF THE MANDIBLE 



189 



and most frequently occur between the third and fourth decennium. 
In 1722 fractures, Lente found 66 (3.19 per cent.) in the inferior 
maxilla, the fracture occurring ten times more frequently in men than 
in women. In children mandibular fractures were seldom observed. 
The combined statistics collected by von Bleichsteiner, comprising 156 
cases of fracture of the lower jaw, showed that 56 occurred in the third 





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Pig. 190. — Fracture of mandible through symphysis. 

and only 7 in the first ten years of life. Of Gurlt's 143 reported cases 
80 were single, 49 double ; and in 14 there were three or more lines of 
fracture. Of the 80 single fractures, 5 involved the alveolar processes, 
in 25 the line of fracture involved the median line, the region of the 
incisor teeth in 22, the region of the molar teeth in 15, posterior to the 
teeth in 8, and the condylar process in 5 instances. In 35 double frac- 
tures in which the line of fracture is described, both sides of the bone 



190 TREATISE ON FRACTURES 

were involved in 20 instances, generally at corresponding" points ; in 
8 cases one side alone was involved, and in the remaining 7 cases the 
median line was involved in one of the fracture lines. 

Etiology. — Fractures of the mandible are usually the result of a 
blow with the fist, a kick, a fall upon the chin, gunshot injuries, or the 
fault}- extraction of teeth. The last form of violence rarely results in 
a direct transverse fracture, but generally in a tearing off of a portion 
of the alveolar process. Most fractures are the result of direct vio- 
lence. A few rare forms' of fracture may be the result of indirect 
violence, as by coughing, a tearing off of the coronoid process by 

violent contracture of the tem- 
poral muscle, or a compression 
of the jaw from side to side, 
accompanying a lateral com- 
pression fracture of the skull. 
The site of fracture in the 
last instance occurs near the 
point of greatest flexion — the 
symphysis. Fracture of the 
neck of the condyloid process 
from a blow on the chin is 
also an example of indirect 

Fig. rpi.— Mandible; old fracture of the body; union, violence. Bilateral fracture of 

The line of fracture is midwav between the svmphvsis ,, ■ r -n • 

and the right inferior dental foramen. Union 'occurred tile Ulterior maxilla IS UllCOm- 

without ileformitv. but with a deficiency at the alveolar ,,, , , . . , 

border which exposes the root of the right incisors. 111011, altllOUgll multiple IraC- 

(Mutter Museum, No. 1169.14). . . , 

tures are fairly frequent. 
Hamilton states that they form about one-third of all cases. Com- 
minuted fractures are rare. Open, the so-called compound, fractures 
are very frequent, because the adherent gum overlying the seat of frac- 
ture is generally torn. Fractures are rare through the symphysis. 

Varieties. — Fractures of the horizontal portion are generally open, 
and of the ramus usually closed. The site of fracture depends upon 
the position of the trauma, the manner in which the blow was received, 
and the presence of any weak point in the bone. The following are 
the usual sites of fracture: 

Fracture Through the Symphysis (Figs. 190 and [91).— This 
is very rare. If comminuted, a portion of the bone may be drawn 
backward by the geniohyoid and geniohyoglossus and at times the 
digastric muscles, and cause symptoms of suffocation. The line of 
fracture if single is generally vertical. 

Fractures at or near the mental foramen (Figs. 192 and [93), 
in the region of the canine tooth, are more frequent than those of 




FRACTURES OP THE MANDIBLE 



191 



the median line. The line of fracture is generally oblique. This is 
a weak part of the bone, which is strong behind this point on account 
of the beginning of the hylohyoid ridge and the protection afforded by 
the masseter muscle. Depending upon the line of fracture, certain dis- 
placements occur. "When the line of fracture runs forward and down- 
ward and from within out, very little if any displacement occurs. 
When its direction is downward and backward, the anterior portion 





^M . :*■ 












\ 



Fig. 192. — Fracture of mandible, ne 



is depressed by the geniohyoglossus, geniohyoid, mylohyoid, digastric, 
and platysma muscles, and the posterior portion is elevated by the 
temporal, masseter, buccinator, and internal pterygoid muscles. If the 
fracture is double, the displacement of the anterior fragment is marked. 
When the line of fracture runs backward from above downward and 
backward from within out, the posterior fragment is drawn inward 
by the internal pterygoid and mylohyoid muscles, and the anterior 
fragment is drawn upward by the action of the internal pterygoid of 
the opposite side. 



192 TREATISE OX FRACTURES 

Fracture through the molar region (Figs. 194 and 195) is not 
uncommon. Here there is very slight displacement of fragments, 
due to the firm attachment of the masseter and internal pterygoid 
muscles. Injury to the vessels and nerves running in the inferior 
dental canal are disagreeable symptoms which may complicate frac- 
tures in this region. 

Fractures through the Angle (Figs. 196 and 197). — A small 
number of fractures occur here. There is generally slight displacement 
upward and forward of the ramus due to the pull of the masseter and 
internal pterygoid muscles with a backward and downward displace- 
ment of the body. 

Fractures through the ramus (Fig. 198) are extremely rare, be- 
cause of the protection afforded by the attached muscles. The line 
of fracture is generally oblique from in front and above downward 

and backward. Dislocation 
of fragments is rare unless 
the fracture is bilateral or 
complicated by a luxation 
of the condyloid process 
of the opposite side. Gen- 
erally the fragments are 
held in apposition by the 
masseter and pterygoid 
muscles. 

Fracture through the 

Fie. 193.— Inferior maxilla; ununited fracture. The fracture con dyloid process ( FigS. 

occurred through the left mental foramen: failing to unite the \ • ,, 

bone is thickened at the seat of fracture and the opposing edges I Q9 — -°- ) ^ generally at 

are rough. (Mutter Museum. No. 1169.13). ,/ ' . ° ." 

the neck, is comparatively 
frequent. and is difficult to treat. Roe reports 6 out of 41 cases of 
fracture of the lower jaw. The displacement in this form is char- 
acteristic. The chin and jaw are pulled toward the injured side. 
especially by the internal pterygoid muscle of the opposite side. This 
lesion is differentiated from dislocation of the jaw by the fact that in 
the latter the chin will point toward the normal side. In bilateral fract- 
ure of the condyloid processes the entire lower jaw will be pushed 
upward and backward and the lower teeth will be displaced behind the 
upper teeth. 

Fracture through the coronoid process are extremely rare. Mod- 
erate displacement of the upper fragment occurs on account of the 
pull of the temporal muscle. These fractures are generally the result 
of direct violence and often are accompanied by fractures of the malar 
and Miperior maxilla or base of the skull. 

Fractures of the alveolar process (Fig. 203) are comparatively 




FRACTURES OF THE MANDIBLE 193 




Pig. 194. — Fracture of mandible, through body. 




Fig. 19s. — Fracture of mandible, malar region, showing type of displacement of fragments. 

13 



194 



TREATISE ON FRACTURES 

red in the faulty extraction of 



frequent. They are generally produce 
teeth, or by a blow upon the teeth. 

Method of Examination. — Examination is accomplished by the in- 
sertion of the index-finger into the mouth while the other fingers, upon 
the chin, seize the lower fragment, and the other hand steadies the 
upper fragment (Fig. 204). By manipulation, displacement of frag- 
ments may be recognized and crepitus may be elicited. It is, however, 








Fig. 196.— Fracture of mane: 



unnecessary to do tins in all cases. Simple inspection of the gums in 
fractures of the body will generally show laceration of submucous 
hemorrhage, and mal-alignment of or looseness of the teeth. 

Symptoms.— The symptoms of a fracture pf the inferior maxilla 
are well marked in fracture of the body and generally obscure in fract- 
ures of the ascending ramus. The displacement, crepitus, and un- 
natural mobility in fracture are easily detected, but one should bear in 



FRACTURES OF THE MANDIBLE 



195 



mind the possibility of mal-positions of the teeth from irregular devel- 
opment and irruption. Pain is a most constant symptom in fracture 




Fig. 197. — Fracture of mandible through malar region, showing type of displacement of fragments. 
The ramus is pulled upward, forward, and inward bv the masseter, temporal, and internal pterygoid 
while the body is displaced backward. 




Fig. 198. — Inferior maxilla; oblique fracture of the ramus; ununited. The left ramus was fractured 
obliquely in a line running from the sigmoid notch near the coronoid process downward toward the 
angle of the bone. (Mutter Museum, No. 1169.21.) 



of the jaw. It is increased by talking and deglutition, and profuse 
salivation is generally present. This increase of saliva and mucus is 



196 



TREATISE ON FRACTURES 



largely relative, the excess being due to the want of proper control of 
the fluids within the mouth. These fluids may be mixed with blood, 
due to the fact that many of these fractures are open. Examination 
will often disclose a tear of the mucous membrane or a submucous 
ecchymosis, and irregularity of the teeth without proper articulation 
of the upper and lower rows. In fractures without displacement, 
crepitus, or mal-alignment of teeth, the only symptoms present may be 
swelling, local tenderness and pain, and inability to freely move the 
lower jaw. In fractures of the neck of the condyle there is generally a 
slight depression in front of the external auditory meatus, and on 




Fie. 199. — Fracture of mandible through neck of condyle. Boy was struck on side of jaw by falling 
rock. Arrow points to displaced condyle. 

movement of the jaw the condyle does not follow its normal range of 
motion. Other late symptoms of fracture are fetor from decom- 
posing food, pus and other secretions, abscess about necrosed frag- 
ments of bone, fistulous tracts and ulcerations of the mucous membrane ; 
and in occasional instances marked general debility due to the swallow- 
ing of foul secretions and deprivation of nutritious food. 

Complications.— The complications of fracture of the inferior max- 
illa may he divided into those due to traumatism and those due to infec- 
tion. The complications due to traumatism are the immediate and the 
delayed. The immediate are severe laceration of face and lips, 
hemorrhage from laceration of the sofl parts and occasional rupture 



FRACTURES OF THE MANDIBLE 197 

of an artery. Coyler reports a case in which a traumatic aneurism 
developed, necessitating ligation of the common carotid. Additional 
immediate complications are dislocation associated with fracture, dislo- 




FlG. 200. — Side view showing the condyloid process "bent" in and forward to almost a right a 
with the ramus, the head resting in the pterygomaxillary fossa. (Courtesy Dr. M. H. Cryer.) 



ight angle 




Fig. 201. — Posterior view of mandible, showing a united fracture of the neck of the left condyle. 
This position is typical for this class of fractures. Through the action of the external pterygoid muscle 
the position of the head of the condyle sometimes interferes with the function of the mandibular nerve 
and vessels. The illustration also shows that there has been another fracture between the canine tooth 
and the second incisor, passing through the bone. (Courtesy Dr. M. H. Cryer.) 

cation and fracture of the teeth, laceration or compression of the in- 
ferior dental nerve, fracture of the base of the skull and cerebral 
concussion. The delayed complications are involvement of the inferior 
dental nerve in callus, delayed or non-union of the fragments, and union 



198 



TREATISE ON FRACTURES 



of fragments, in such a position that correct articulation of the upper 
and lower teeth is not possible. 

Of the complications due to infection, the most frequent and im- 
portant is necrosis of the ends of the fragments. This condition may 
lead to delayed union, or pseudo-arthrosis, to abscess, salivary fistula, 
septicaemia and pyaemia. Stomatitis is also a frequent complication. 

Diagnosis. — The diagnosis of fracture of the mandible is, as a rule, 
made without difficulty. In condylar fracture diagnosis may be diffi- 
cult. Usually crepitus may be obtained, and this, combined with the 
history of violence, local tenderness on pressure, the presence of a 




Fig. 202. — An anterior view of the same skull. The left condyle is seen in the left ptervgomaxillary 

fossa. (Courtesy Dr. M. H. Oyer.) 

Fk,. 203.— Fracture of mandible through base of anterior part of alveolar process. 

depression anterior to the external meatus, and the failure of the 
condyle to follow the movements of the lower jaw on motion of the 
latter, will generally clear up the diagnosis. In most of the instances 
the diagnosis may be made from deformity, pain on motion, chewing 
or talking, crepitus, profuse salivation often streaked with blood, 
laceration of the mucosa, and localized pain on pressure or motion. 
Fractures of the coronoid process can only be suspected clinically by 
local tenderness on pressure inside the mouth and pain on motion. 
Crepitus may or may not be elicited. Radiograms will solve most 
cases with greal readiness. 



FRACTURES OF THE MANDIBLE 



199 



Prognosis. — Union of uncomplicated fractures without laceration 
of the mucous membrane generally occurs within from five to six weeks. 
The prognosis, even in bad cases, is ultimately good. Extensive and 
severe open fractures are often followed by surprisingly good results. 
In open comminuted fractures delayed union may result for a time, 
but eventually union takes place after the discharge of sequestra. 
Pseudo-arthrosis is rare. Norris reports only two cases of non-union 
in 150 fractures; and the statistics of Muhlenberg and Berenger- 
Feraud show that they form only 2 per cent, of all pseudo-arthroses 
observed. Many of the disturbances referable to the inferior dental 
nerve are temporary. The presence of severe neuralgia, anaesthesia 
aud paralysis are generally due to the presence of a blood clot pressing 




upon the inferior dental nerve, rather than to any actual lacerations or 
bony compression of the nerve. When pressure is produced by bony 
fragments it is generally in fractures posterior to the mental foramen. 
In prolonged symptoms of compression, relief may be obtained bv 
operative exposure of the nerve. Fractures of the condyloid process 
may be followed by ankylosis of the temperomaxillary joints. In 
fractures of the coronoid process fibrous union is the rule, and there is 
generally no interference with subsequent mastication. 

Treatment. — In the treatment of fractures of the inferior maxilla, 
two points should be carefully considered. First, the proper reduction 
and retention of the fragments, and, second, the care of the mouth. 
Failure of union in fractures of the inferior maxilla may frequently 



200 



TREATISE OX FRACTURES 



be traced to the lack of proper oral asepsis. In all cases our primary 
consideration should be avoidance of a stomatitis with its resulting 
sepsis and necrosis. This is particularly important, as nearly all frac- 
tures are open. The utmost care should therefore be used to disinfect 
the mouth and keep it clean. Thorough irrigation with a mild anti- 
septic solution should be performed after each meal. 

Reduction of the fragments by pressure of the fingers on the teeth 
is usually easy, though occasionally comminuted fragments or displaced 
teeth may cause interlocking and require removal before correct ap- 
position is obtainable. Teeth which are simply loosened should not 
be removed unless they prevent proper reduction. Care should be 
taken to maintain the " bite " — the normal relation of the upper and 




- 

in splint in place in fracture of the 



the lower teeth. Union in most cases is fairly firm at the end of three 
weeks, and very little retentive apparatus is required after the fourth 
week. Reduction in fractures of the condyle may generally be ob- 
tained by foil, .wing the suggestion of Ribes. which consists in first 
pulling the jaw forward and then pressing the condyle from within 
outward by the finger placed upon the upper, lateral wall of the 
pharynx. Reduction in all other cases is generally easy. 

While reduction is simple, as a rule, its maintenance is often, diffi- 
cult or impossible. In many cases the simplest measures will retain the 
fragments in their proper position. The various methods of maintain- 
ing reduction may lx- grouped as follows: External dressings: com- 
bined external and internal dressings or splints: internal splints: and 
wiring or some other method of direct fixation. 



FRACTURES OF THE MANDIBLE 



201 



External Splints. — The simplest form of external dressing is the 
Barton bandage of the occiput and chin; or moulded chin splint (Figs. 
205 and 206), or a Lewis metal chin splint held in place with an occip- 
itomental roller bandage or a four-tailed bandage. 

These dressings are useful as temporary dressings during the manu- 
facture of an interdental splint, but as a permanent dressing, in the 
presence of any marked tendency toward displacement of fragments, 
they are not satisfactory. 

The objections to their use are the necessity of tight bandaging of 
the lower to the upper jaw, which entirely prevents mastication, and 
the tendency to displacement of fragments which is not overcome. In 
certain cases, notably oblique fractures in the region of the mental 
foramen, the external pressure produced by them may tend to increase 
the displacement. 




Pig. 207. —A fracture of the mandible, showing interdental splint in position. (Courtesy of Dr. M. 
H. Cryer.) 
Fig. 208. — An interdental splint holding the mandible together where a pathological separation 
of bone occurred, causing the loss of a complete section of bone. New bone filled in the parts, leaving 
no disfigurement or shortening of the jaw. (Courtesy of Dr. M. H. Cryer.) 

Two splints are in use which cause fixation of the fragments by 
means of vulcanite interdental splints and an external figure-of-8 
bandage. These two splints are known as the Gunning and the Hern 
modification of the same. The Gunning splint consists of two rounded 
vulcanite caps for the upper and lower teeth joined together by sup- 
ports. These caps are filled with gutta-percha. After insertion of the 
splint the jaw is fixed between it and a figure-of-8 bandage. 

The Hern modification of the above consists of a vulcanite cap 
covering the teeth and the alveolar border of the inferior maxilla. 
Blocks or pillars are built upon the upper surface of the splint; these 
contain indentations corresponding to the upper teeth. The recesses of 
the vulcanite contain gutta-percha for articulation with the upper 
teeth. The splint is applied like the Gunning and is held in place by a 



202 



TREATISE OX FRACTURES 



skull and chin cap. with connecting bands of elastic to produce constant 
pressure. 

Interdental Splints and Dressings. — Of the various methods of 
interdental splinting, the most notable and practical are those of Ham- 
mond. Angle. Payne, Saner. Hohl, Schauber, Schellhorn and Xeder. 

The simplest forms of interdental splints are the Hammond, Angle, 
and Payne. The Hammond splint is made by bending soft iron wire 
and moulding it as accurately as possible to a model taken previously. 
The wire is fitted to the lingual and buccal sides of the teeth, the ends 
being soldered together. If necessary, the wire may be fitted directly 
to the teeth. "When the splint has been made, the fragments are 




PlG. 200. — An interdental splint used in case of a compound fracture of the mandible. At first 
the parts weie wired together with bad results: the wire was removed and a splint was cemented in 
position. In six weeks time the parts had united. (Courtesy of Dr. M. H. Cryer.) 

Fig. 210. — Two compound fractures at the angles of the mandible treated by a mandibulomaxillary 
splint. consisting of two interdental splints, upper and lower, soldered together and cemented so that 
the teeth are held together in their normal position. Although there is no hold of the rami by the splints 
they will adjust themselves to the other end of the bone. (.Courtesy of Dr. M. H. CryerJ 



reduced, the splint placed in position, and the teeth fixed to the splint 
by means of ordinary iron or silver wire. When there are a number 
of teeth present those close to the seat of fracture should not be bound. 
After the end of a week the wires should be tightened. The splint de- 
vised by Claude Martin, of Lyons, is a modification of the above and 
consists of three silver wires approximately the form of the dental 
arch, and which are connected to each other at intervals by transverse 
wires, and is held to the teeth by means of silk thread. The Angle 
splint consists of encircling bands of metal applied to several approx- 
imating upper and lower teeth. These bands are adjusted to the in- 
dividual teeth, are tightened, and the outer surface of each band has a 
small projection to which wires are attached, joining the upper and 
lower bands and holding fast the upper and lower teeth. The Payne 



FRACTURES OF THE MANDIBLE 



203 



splint is made of a silver wire framework fitted to the necks of the 
upper and lower teeth on the labial and lingual aspects, the wire being 
carried around the arch as far as it is necessary. The ends of each half 
of the framework are soldered together and at several intervals trans- 
verse bars are fixed. The two arches are united by rods on the labial 
and lingual sides and the splint ligatured to the teeth by means of fine 
silver wire. Tbe advantages of tins splint are that the fragments are 




of fragments in fracture of the mandible 



held in good position, the teeth and mouth can be readily cleansed, and 
the condition of the jaw observed. 

The two most useful forms of splints for fracture of the mandible 
are the interdental splint and the mandibulomaxillary splint. These 
are made of aluminum or gold. The interdental splint (Figs. 207-209) 
is made to fit the crowns of all the lower teeth at each side of the seat 
of fracture, after reduction of the fragments, the splint is cemented in 
place, and the use of this splint allows of opening and closing the 



204 TREATISE ON FRACTURES 

mouth for inspection. The mandibulomaxillary splint (Fig. 210) is 
made of aluminum or gold. It is made to fit the crowns of all of the 
upper and lower teeth, and after reduction of the fragments it is 
cemented to the teeth. It does not allow of opening and closing of the 
mouth, and does not allow of mastication. It is particularly useful in 
double fracture of the mandible. 

Another useful form of interdental splint is one made of aluminum, 
which fits the crowns of the teeth at each side of the seat of fracture 
and allows opening and closing the mouth for inspection. 

Suture of the fragments with silver wire or silver-plated copper 
wire has been used rather extensively at times. The cases in which 
this form of retention is indicated are limited. Various methods of 
using wire are in vogue. Perhaps the simplest is to drill holes in 
each fragment, at least one-fourth of an inch away from the seat of 
fracture. The hole in the depressed fragment should be drilled at a 
lower level than the one in the other fragment, so that in tightening 
the wire there is a lifting tendency and a great resistance to recurrence 
of deformity. After intri iducing the wire the fragments of bone should 
be drawn together, the wire twisted and cut, and the sharp cut ends 
covered by a small piece of rubber tubing (Fig. 211). Screws or 
steel plates may be used in a manner similar to that employed in fixa- 
tion of bones of the extremities. They are, however, rarely used. 

In difficult cases of fracture of the lower jaw with displacement of 
fragments, the aid of a competent dental surgeon should be secured in 
the preparation and application of a suitable interdental splint. Frac- 
tures at certain positions require various forms of splinting. Metal 
splints of aluminum are undoubtedly the best for fractures of the body 
or alveolar process. The Hammond splint and the aluminum moulded 
splint are undoubtedly two of the best for fractures in this region. 
Fractures about the angle may be treated by an outside gutta-percha 
splint so made as to pass backward and thus support this angle. This 
splint can be kept in position by a Barton bandage. Fractures of the 
ascending ramus, condyle, or coronoid process are best treated by the 
method of Angle, or. if this is impracticable, fixation may be obtained 
by external dressings, as the Barton or four-tailed bandage. 



CHAPTER VIII 

FRACTURES OF THE HYOID BONE 

Anatomy. — The hyoid (Fig. 212) or lingual bone is a small horse- 
shoe-shaped bone situated at the base of the tongue between the chin 
and the thyroid cartilage. It consists of a body, two greater cornua, 
and two lesser cornua. The body has a concave posterior surface 
directed backward and downward toward the epiglottis. The greater 
cornua are tapering processes arising from the sides of the body, are 
directed upward and backward, and end in a small bulbous tubercle to 
which the thyrohyoid ligaments are attached. They may be connected 
to the body by either bony tissue or fibrocartilage. The lesser cornua 
arise from the bases of the greater cornua, extend upward and back- 




Great cornu 



Fig. 212. — The hyoid bone, anterior view. (Piersol s Anatomy.) 

ward, are at times cartilaginous, are shorter than the greater cornua, 
and are connected with the styloid processes of the temporal' bones by 
the stylohyoid ligament. 

Surface Markings. — The hyoid bone may be palpated through- 
out. Its position is directly behind the chin. The greater cornu is the 
landmark for the location of the origins of the superior thyroid, 
lingual, and facial arteries. 

Statistics. — Gurlt's collected statistics of 27 cases showed in 21 
cases fractures of the bone alone, and in the remaining cases there 
were associated fractures of the thyroid or cricoid cartilage or of the 
trachea. Of the 13 collected cases reported by Gibbs, 7 followed 
strangulation, 3 were the result of a blow or a fall, and 3 were due to 
muscular action. 

Etiology. — Fractures of the hyoid, owing to its sheltered position, 
its elasticity and mobility, are extremely rare. Fractures are usually 

205 



206 



TREATISE ON FRACTURES 



the result of direct violence as from a blow or fall, pressure of the rope 
in hanging, or grasping the throat (Fig. 213) as in homicidal assaults. 
It has been broken as the result of muscular action. In fractures due 
to direct violence the break usually occurs near the junction of the 
greater horn. 1 nose of the body itself are usually the result of a blow 
or a kick. Fractures of the lesser horn are extremely rare. In hyoid 
fracture there is generally considerable displacement of the fragments : 
and the injury may be associated with fracture of the laryngeal 
cartilages. 

Symptoms. — The symptoms are localized pain, tenderness, and 
swelling in the region of the hyoid, pain on opening the mouth or on 



■ - 
I 






\ 



Fig. 213. — Fracture of the hyoid bone. Occurred during the extraction of a molar tooth while 
'"<-■ patient was under nitrous oxide anajsthesia. The dentist pressed on the hyoid bone with his hand. 
mplained of hoarseness, but there was no oedema present. 



protruding the tongue, painful deglutition, difficulty in talking, dys- 
pnoea, occasional oedemaof the larynx with its accompanying symptoms, 
local ecchymosis, crepitus, abnormal mobility and displacement of frag- 
ments, and if the mucous membrane of the pharynx is lacerated, bleed- 
ing from the mouth. Sometimes the displaced fragment may be 
in the pharynx. Coughing, with paroxysms 
dlowing or pro- 



readily fell with the fmgi 
1 rf choking or asphyxia, 
truding the tongue. 

Complications. — The 



follow attempts at 



implication 



fracture of the hvi 



FRACTURES OF THE HYOID BONE 207 

accompanying injuries to the laryngeal cartilages, hemorrhage from 
pharyngeal vessels, oedema of. the larynx, abscess, and necrosis of 
fragments. 

Diagnosis. — The diagnosis can usually be made from the history 
of injury, the presence of crepitus, displacement of fragments, dys- 
pnoea, and dysphagia. 

Prognosis. — Simple, uncomplicated fracture of the hyoid should 
not be followed by untoward results. In the presence of laryngeal 
complications death may result from oedema of the glottis. 

Treatment. — Reduction of displaced fragments is as readily accom- 
plished as retention in their normal position is difficult. Replacement 
can generally be made by manipulation with a finger in the pharynx, 
combined with external pressure. The fragments may be retained in 
fair approximation by immobilization of the head and neck by ex- 
tension and sand pillows, or by means of a stiff collar. Dyspnoea with 
development of oedema of the larynx will necessitate low tracheotomy, 
and dysphagia may necessitate the use of a stomach tube. Union of 
fragments in a deformed position or non-union may require excision 
of the displaced fragment. 



CHAPTER IX 

FRACTURES OF THE CARTILAGES OF THE LARYNX 
AND TRACHEA 

Anatomy. — The larynx is in relation above with the hyoid bone, 
below with the trachea, and is opposite to the lower three cervical 
vertebra?. It is formed of three single cartilages, the thyroid, the 
cricoid and the epiglottis, and three or four pairs of smaller cartilages 
called the arytenoid, the corniculate, the cuneiform and the cartilagines 
triticeal. 

The thyroid is the largest of the laryngeal cartilages and is situated 
above the cricoid cartilage. It presents on each side an ala, and in the 
centre a notch formed by the union of the two alae. On the posterior 
border of each surface there arise the superior and inferior cornua. 

The cricoid is the lowest of the cartilages of the larynx and re- 
sembles a signet ring. It is connected with the thyroid by the crico- 
hyoid ligaments. The other cartilages are unimportant in relation to 
fractures. 

Fractures of the Trachea — Anatomy. — The trachea or windpipe 
is situated in the anterior lower part of the neck. It lies in front of 
the cesophagus and extends downward from the lower border of the 
larynx to its termination in the bronchi, which is from the level of the 
sixth cervical to that of the fifth thoracic vertebra. It is formed by 
sixteen to twenty cartilaginous rings, which are open posteriorly for 
about one-third to one-fifth of their diameter and are joined to one 
another by the annular ligaments. 

Surface Markings. — The thyroid cartilage of the larynx forms the 
so-called "Adam's apple," in the anterior part of the neck below the 
hyoid bone. It is most prominent in males, is entirely cartilaginous : 
and its body, borders and cornua can be readily palpated. The cricoid 
cartilage lies immediately below the thyroid cartilage, is seal-ring in 
shape, and can be readily felt with the fingers. 

The trachea is situated just below the cricoid cartilage, and about 
one to one and a half inches of its upper end may be examined with 
the fingers. On marked extension of the neck another inch may be 
palpated. The rings of the second, third, and fourth cartilages are 
generally covered by the isthmus of the thyroid gland. The portion 
just above the sternum is situated rather deeply on account of the 
recession of the upper cervical and thoracic vertebrae. 

Statistics. — Fractures of the larynx and trachea, owing to the ex- 
posed position of the larynx, are more frequent than fracture of the 
208 



FRACTURES OF THE LARYNX AND TRACHEA 209 

liyoid bone. Hoffmann, who collected statistics of 145 cases, shows 
that in 122, in which the cause was given, 84 were the result of ac- 
cident, 36 were due to suicidal attempt or homicidal violence, and 2 
were the result of undue muscular action, such as coughing and blow- 
ing. Remer reports one case of fracture in 201 cases of hanging ex- 
amined; and Hoffmann and Lesser found 16 cases of fracture in 50 
cases of suicidal hanging. The collected statistics of 6j cases reported 
"by Stimson showed isolated fracture of the thyroid in 24 cases with 
18 deaths ; of the cricoid in 1 1 cases with 1 1 deaths ; of the thyroid and 
liyoid, 5 cases with 3 deaths : of the thyroid and cricoid, 9 cases with 9 
deaths ; of the thyroid, cricoid and hyoid, 2 cases with 2 deaths ; of the 
thyroid, cricoid and trachea, 4 cases ; of the cricoid and trachea, 2 cases 
with 2 deaths; with the cricoid, trachea and hyoid, 1 case with 1 death; 
of the larynx, 7 cases with 3 deaths ; and of the trachea alone, 4 cases 
with 3 deaths. Hoffmann's recent statistics as to the sexual distribution 
shows that there were 64 men and 9 women; and of 54 of these cases 
1 occurred during the first ten years, 9 during the second ten years, 10 
during the third ten years, 15 during the fourth ten years, 9 during 
the fifth ten years, 7 during the sixth ten years, and 3 during the 
seventh ten years. In regard to the site of fracture, Hoffmann's sta- 
tistics of 124 cases show that the thyroid cartilage was the seat of 
fracture 63 times, the cricoid cartilage 17 times, the arytenoid cartilage 
once, and in 43 instances there were fractures of several cartilages or 
of the liyoid and larynx. 

Etiology. — The causes of fractures of the cartilages of the larynx 
and trachea are blows, falls, hanging, homicidal throttling, muscular 
action, and incised and gunshot wounds. Fractures are generally 
produced by lateral compression or by anterior pressure directed back- 
ward toward the vertebral column. Fractures of the thyroid are 
usually vertical near the median line, if produced by lateral pressure; 
the lines of fracture, however, may be longitudinal, irregular, com- 
minuted, or transverse. Fracture of the cricoid is generally bilateral, 
and a single fracture in the median line is rare. Fractures of the 
arytenoids are generally seen in conjunction with fractures of other 
cartilages. 

Fractures of the trachea are extremely rare and often they go un- 
recognized before death. Brigel has reported 33 cases and Hoffmann 
has added 12 more cases. The causes of fractures of the trachea are 
generally the same as those of fracture of the larynx. In addition may 
be mentioned over-stretching of the trachea, and compression of the 
upper part of the chest. In Hoffmann's reported statistics children 
were affected in 13 cases, and in 17 cases the fractures were asso- 
ciated with fracture of the larynx or of the hyoid, and there were 
complicating injuries of the ribs or sternum in 19 cases. 
14 



210 TREATISE OK FRACTURES 

Symptoms. — The symptoms of fracture of the cartilages of the 
larynx are deformity, abnormal mobility, cartilage crepitus accom- 
panied by a convulsive cough, alteration in or loss of voice, dyspnoea, 
dysphagia, often blood-streaked sputum, and in many cases emphysema 
extending over the neck, face and trunk. Interference with respira- 
tion may not be pronounced at first, but it is generally progressive, so 
that after a time here are stridor, cyanosis, marked dyspnoea and the 
development of a rapid pulse and all evidences of respiratory failure. 
The interference of respiration may be due to oedema of or hemor- 
rhage into the mucous membrane, dislocation of fragments, or the 
closure of the calibre of the larynx or trachea by cellular emphysema. 
In severe cases death may be due to suffocation from subcutaneous 
hemorrhage, to free bleeding into the larynx, or to inflammatory or 
emphysematous swelling. 

In fractures of the trachea the subjective symptoms differ little 
from those seen in fractures of the larynx. There may be, in addi- 
tion, however, gurgling and tracheal rales, and marked dyspnoea in the 
beginning. The classical symptoms of fracture, crepitus and abnormal 
mobility, are generally impossible of demonstration. 

Complications. — The complications of fracture of the cartilages of 
the larynx and trachea are oedema and intra- and perilaryngeal and 
tracheal hemorrhage. 

Diagnosis. — The diagnosis of fractures of the cartilages of the 
larynx can generally be made by the history of the case, the evidences 
of external injury, and the results of laryngoscopic examination. In 
the early stages there may be oedema, or hemorrhagic extravasation, 
circumscribed or diffuse, discovered by laryngoscopic examination. If 
these conditions are excessive it may be impossible to make a thorough 
examination. 

In fractures of the trachea the diagnosis will be determined largely 
by the presence of associated injuries to the larynx and the intra- 
thoracic symptoms of compression. 

Prognosis. — In all fractures of the cartilages of the larynx and 
trachea the prognosis is very grave, although not so grave as formerly 
was supposed. This is shown by the statistics of Hoffmann. Of the 
j$ reported cases prior to [879 there were 16 recoveries and 59 deaths; 
of the 70 cases since that year there were 40 recoveries and 26 deaths. 
In many of the fatal cases death may occur soon after the accident, 
but it may be delayed for several days. Death in nearly all cases is 
<\\w lo (edema of the glottis, to the displacement of fragments, to the 
inspiration of blood, to mediastinal emphysema, or to secondarv hemor- 
rhage. ( )ther causes of death are septicaemia and aspiration pneumonia. 

Treatment. — The primary indication in treatment of laryngeal 
fractures is to maintain a free current of air to and from the lungs. 



FRACTURES OF THE LARYNX AND TRACHEA 211 

For this purpose tracheotomy is necessary in a large majority of cases. 
If there is any evidence of oedema of the glottis or intralaryngeal 
hemorrhage, or a tendency to displacement of fragments, or to dys- 
pnoea or emphysema, a tracheotomy should be performed. The onset 
of partial or complete obstruction may be very sudden, and unless 
measures are at hand to promptly perform a tracheotomy, death will 
occur before relief can be given. Some authorities even go so far as 
to state that a tracheotomy should be performed as soon as a diagnosis 
has been made. If, however, there are no distressing symptoms, if 
the patient is in a hospital and has the constant attendance of a surgeon 
with all the necessary instruments at hand, a tracheotomy may be de- 
layed. In addition to the above procedure one should endeavor to keep 
the patient quiet, replacing fragments when possible, keeping the parts 
aseptic, and preventing subsequent hemorrhage. We do not recom- 
mend the division of the larynx in the median line and the packing of 
the larynx with gauze as advised by Wagner, or the use of a glass 
cannula as recommended by Mikulicz. The performance of trache- 
otomy and use of opiates should be the primary course of treatment. 
Later indications for surgical intervention should be met as they arise. 
In fractures of the trachea, tracheotomy is always indicated and a 
tube large enough to go beyond the seat of fracture should be used. 



CHAPTER X 

FRACTURES OF THE VERTEBRJE 

Anatomy. — The vertebral or spinal column (Fig. 214), composed 
of a series of vertebra?, is the central part of the skeleton, and is in 
the median line posteriorly. It supports the head above, the ribs on 
each side. and. through the latter, the upper extremities. It trans- 
mits the weight of the body through the pelvic bones to the lower 
extremities. It surrounds the spinal cord and affords exits for the 
spinal nerves. The vertebral column consists of from 32 to 35 
vertebra?; of these 24 are true vertebra?, and 8 to 11 false vertebra?. 
The true vertebra 3 may be divided as follows: 7 cervical, 12 dorsal or 
thoracic, and 5 lumbar vertebra?. The false vertebra? vary in number 
and form two bones, the sacrum and the coccyx. The typical vertebra 
is composed of a body, a neural arch behind, forming with the body 
the spinal foramen, and a number of processes. The neural arch is 
formed by two halves, and consists of two pedicles and two lamina? 
which support seven processes, four articular, two transverse and one 
spinous. The first and second cervical vertebra? differ from the re- 
maining true vertebrae. The atlas or first cervical vertebra has no 
body or spinous process, is formed of a ventral and dorsal arch and 
two lateral masses. The body may be represented by the odontoid 
process of the axis. The axis or second cervical vertebra is character- 
ized by a large, strong body and a large process arising from the 
superior surface of the body called the odontoid process. The atlas 
rotates around this process as a pivot and with it the head also rotates. 

The sacrum is formed earl}- in life of five segments, which later be- 
come fused to form one bone, the os sacrum. It articulates above with 
the fifth lumbar vertebra, below with the coccyx, and laterally with the 
two innominate or hip-bones, forming with the last the pelvic girdle. 

The coccyx is composed of from three to five rudimentary vertebra?, 
fused together and tapering from above downward. In early life. 
especially in the female, they may be movable upon one another and 
ui>on the sacrum. Later in life, the joints between the coccygeal ele- 
ments themselves and that between the first part of the coccyx and the 
sacrum become ankylosed. 

On viewing the spinal column laterally, it will be noted that there 
are four curves. In the cervical and lumbar regions the curves are 
convex forward, in the thoracic and sacral regions the curves are con- 
vex backward. The thoracic and sacra! curves are primary, are found 
in the embryo, and are for the accommodation of the thoracic and 
pelvic viscera. The cervical and lumbar curves, being compensatory, 
212 



FRACTURES OF THE VERTEBRAE 



213 



\ 1. Cervical (atlas) 



Thoracic 



are secondary and are developed later in life. The weakest part of 
the vertebral column is at the junction of the second and third cervi- 
cal vertebrae. The vertebras most subject to fracture, however, 
are from the tenth thoracic to the second 
lumbar vertebras. This is because at that 
point the fixed thoracic part meets the most 
movable part of the lumbar region, great 
leverage takes place, and the lateral proc- 
esses are not so marked as above and below. 

The vertebral column is completed by 
its ligamentous attachments and by the in- 
tervertebral disks situated between the 
bodies of the vertebrae. The ligaments are : 
The anterior longitudinal ligament, which 
begins at the pharyngeal tubercle at the 
base of the skull and terminates on the an- 
terior surface of the sacrum. It is firmly 
attached to the anterior surface of the 
bodies of the vertebrae and intimately con- 
nected with the intervertebral fibrocartilages 
and laterally with the periosteum of the 
bodies. 

The posterior longitudinal ligament be- 
gins at the second cervical vertebra and ter- 
minates in the sacral canal. It is attached 
to the posterior surfaces of the bodies of 
the vertebrae. 

The second group of ligaments connect 
adjoining vertebrae to each other, and may 
be divided into those connecting the arches 
and those joining the processes. They are 
the following: ligamenta flava between the 
vertebral arches ; intertransverse ligaments, 
connecting the transverse processes of the 
vertebrae; interspinous ligaments, connect- v 
ing the spinous processes of contiguous ver- 
tebrae ; supraspinous ligaments connecting Pi G . 2 i 4 .- 
the apices of the spinous processes ; liga- 
mentum nuchas running from the spinous process of the seventh cervical 
vertebra to the external occipital protuberance. 

The articulation of the sacrum with the coccyx is formed by the 
anterior sacrococcygeal, the lateral sacrococcygeal, the posterior coccy- 
geal, the superficial posterior sacrococcygeal and deep sacrococcygeal 
ligaments. 



21-4 



TREATISE OX FRACTURES 



One of the most important ligaments of the spinal column is the 
transverse ligament of the atlas which divides the spinal foramen of 
the atlas in two portions, surrounding the odontoid process of the 
axis posteriorly and allowing space behind for the spinal cord. 

Surface Markings. — Extending in the middle line of the back 
from the skull downward to the sacrum there is a furrow, well marked 
in muscular individuals. Above it is called the nuchal furrow, below 
the spinal furrow. The spinous processes may be felt at the bottom of 
this furrow from the atlas to the sacrum. In thin persons there is no 
furrow, but a ridge running down the centre of the back due to the 
successive spinous processes. The dorsal and lumbar spines are more 
readily palpable on marked flexion of the spine. Normally there are 
four anteroposterior curves — the cervical and lumbar are convex for- 
ward, the thoracic and sacral are concave forward. Normally there 
are no lateral curves to the spinal column. The position of the pos- 
terior superior spine of the ilium on each side of the lumbar region of 

Fig. 215. Fig. 216. 




IS and 2i'>. — Method of palpation through the mouth of the anterior surface of the bodies of 
the upper cervical vertebrae. (Modified after Cotton.) 

the back is marked by a depression at a point just above and external 
to the third sacral vertebra. The spines of the vertebrae may be used 
in locating various structures. The bodies of the first four cervical 
vertebrae may be palpated through the mouth (Figs. 215 and 216), 
and the bodies of the lumber vertebrae may be palpated through the 
abdomen in very thin or emaciated individuals, and the coccyx through 
the anus 1 Fig. 217), 

Statistics. — Berghausen, in a study of [39 cases of fracture of the 
spine, found the following to be the percentage of the vertebrae af- 
fected: cervical, third. 7 per cent.; cervical, sixth. 8 per cent.: dorsal, 
fourth and fifth, 9.5 per cent. ; dorsal, tenth and eleventh. 1 1 per cent. : 
dorsal, twelfth. 25 per cent.; lumbar, first, 14 per cent. Menard, in a 
collection of 385 cases of fracture of the vertebrae, gives the location 



FRACTURES OF THE VERTEBRAE 



215 



of the fracture as follows: first dorsal, 12 cases; second dorsal, 10 
cases; third dorsal, 8 cases; fourth dorsal, 9 cases; fifth dorsal, 15 
cases; sixth dorsal, 10 cases; seventh dorsal, 10 cases; eighth dorsal, 
20 cases; ninth dorsal, 25 cases; tenth dorsal, 32 cases; eleventh dor- 
sal, 37 cases; twelfth dorsal, 80 cases; first lumbar, 78 cases; second 
lumbar, 23 cases; third lumbar, 6 cases; fourth lumbar, 7 cases; 
and fifth lumbar, 1 case. 

Etiology. — Fractures of the spine are observed generally in men, 
in adult life, and especially in those whose occupation exposes them 
to such injuries as produce fracture of the vertebrae. Women are 
rarely affected, no cases of children under sixteen years have been 
found by us, and it is rarely seen in those of advanced life. Frac- 
tures are the. result of direct or indirect force and rarely of muscular 
action. The most frequent cause of vertebral fracture is an indirect 
force which tends to produce hyperextension or hyperflexion of the 
spine's normal curves, most frequently 
hyperflexion. Such traumatism oc- 
curs in a fall upon the head or shoul- 
ders, a fall from a height upon the 
buttocks, a crush under a weight fall- 
ing from above upon the head or 
shoulders, or being jammed under a 
low arch when sitting on a car or 
wagon. Fracture results because the 
limit of flexion or extension has been 
exceeded and the bony segments are 
crushed or lacerated by the force. 
The fracture in such instances usually 

OCCUrS where a movable portion O-f through the anus. (Modified after Cotton.) 

the spine joins a more rigid portion, because it is at this point that the 
sudden check to movement occurs. Hence, clinical experience shows 
that fractures of the vertebrae are most frequent near the dorsolumbar 
junction and in the vicinity of the cervicodorsal region. 

Fractures occurring from direct violence are generally due to the 
striking of the back upon a projecting object, or to a falling object 
striking the back while the patient is stooping over. Fractures by 
muscular action are rare, but cases have been recorded in which this 
has occurred, as in diving. Most fractures received in diving are due 
to impact of the head on the bottom in shallow waters acting as do falls 
on the head or shoulders. The sudden throwing back of the head in 
order to avoid a shallow bottom has been ascribed as sufficient to cause 
fracture with dislocation of the cervical vertebrae. Wrestling has been 
the cause of spinal fracture or dislocation by over-flexion or over- 
extension at the hands of an opponent. 




Fig. 217. — Method of palpation of the coccyx 



216 



TREATISE ON FRACTURES 



The bodies of the vertebrae seem to be involved more frequently 
in the lower than in the upper region, while the arches are more fre- 
quently fractured in the cervical region than elsewhere. Fracture of 
the spinous processes occurs most often in the dorsal region. The 
lines of fracture and the number of vertebrae involved depend upon 
the direction and the degree of the force. 

Fracture is often accompanied by dislocation, and in many cases 
the two conditions are indistinguishable except at autopsy. Fracture 
of two or more vertebrae is common in the cervical and upper dorsal 
regions, less common in the lower dorsal and rare in the lumbar 
region. 




Fie. 218. — Compression fracture of the body of the fourth dorsal vertebra (Kocher). 
Fit,. 210. — Fracture-dislocation of the fourth and fifth dorsal vertebra; (Kocher). 

Varieties of Fracture. — Kocher describes the following varieties 
of vertebral fracture : isolated fracture of the bodies ; isolated fracture 
of arches, spinous processes and transverse processes; and fracture- 
dislocations. 

Isolated Fracture of the Bodies of the Vertebras ( Figs. 2 1 8-224 * • 
— These fractures are always the result of compression. They are 
produced by a force acting in the long axis of the spine, in those 
portions of the column which have a supporting function, namely, 
the anterior column of the vertebral bodies, the intervertebral disks, 
and the double column of articular processes. When a compressing 
force is acting in the longitudinal axes of the spine, there results, first, 
shortening of the articulation processes behind, flexion and com- 
pression of tlie vertebral bodies and intervertebral disks until the bum 



FRACTURES OF THE VERTEBRAE 



217 



of their elasticity is reached, when compression fracture of the bodies 
of the vertebrae occurs, and, in addition, fractures of the intervertebral 
disks. Compression fractures are found most often where the flexi- 
bility of the spine is the least. In the cervical region flexibility is the 
greatest and in the dorsal and upper lumbar regions it is very limited. 
In the region where flexibility is greatest the intervertebral disks are 
found to be relatively thickest in comparison with the thickness of 
the vertebral bodies. The relative thickness of the disks is greatest in 
the cervical region ; and the thickness of both bodies and disks increases 
from above downward. Compression fractures of the bodies of the 




Fig. 220. — Last three dorsal and first lumbar vertebras. Fracture of the body of the twelfth dorsal. 
The body of the twelfth dorsal is crushed by pressure from above. The anterior border of the superior 
articulating surface is destroyed. From a man who was crushed by the fall of a bank of earth. The 
man died instantly upon being turned in bed while in the hospital. (Mutter Museum, No. 1188.30.) 

Fig. 221. — Ninth, tenth, eleventh and twelfth dorsal, and first two lumbar vertebrae. Fracture of 
the last dorsal. Recent. The first lumbar is fractured by force vertically applied. The compact 
tissue of the body L s forced forward and outward in sections, vertical fissures being seen at four places. 
The vertebral canal has been exposed on the left side and shows a fracture of the right lamina. 
(Mutter Museum, No. 1188.40.) 

Fig. 222. — Eleventh and twelfth dorsal and first lumbar vertebrae. Vertical facture of the twelith 
dorsal and crescentic fracture of the upper and anterior lip of the fiist lumbar. Recent. The last dorsal 
is severely crushed. On the left the body is fissured transversely at the middle. The ve; tical force has 
fractured the first lumbar vertebra at the anterior margin. The patient did net survive the accident 
long. (Mutter Museum, No. 1188.20.) 

vertebrae are most frequently seen in the dorsal and upper lumbar 
regions, and least frequently seen in the upper third of the dorsal and 
lower lumbar regions. Kocher found, in a study of 23 isolated frac- 
tures of the bodies of the vertebrae, that the lesion had occurred from 
the eighth to the twelfth dorsal vertebra, 11 times, and the lumbar 
vertebrae, 7 times; and that the twelfth dorsal and first lumbar vertebrae 
were involved 5 times. 

In compression fractures of the bodies of the vertebrae, the bodies 
of one or more vertebrae are compressed or flattened out, the shape 
of the body is changed by the compressing force to a wedge-shaped 



218 



TREATISE OX FRACTURES 



mass, the crushed portion of the body becomes more dense, and as the 
vertical diameter is diminished, the horizontal diameter is increased. 
In other less typical cases, fragments may be broken out of the upper 
anterior edge of the body, and are produced by the upward pressure 
of the anterior lower margin of the compressing vertebrae (anterior 
wedge fragments). In addition there is sometimes a crushing out 
posteriorly into the vertebral canal of fragments of bone (posterior 
wedge fragments). If the violence is severe or prolonged, dislocation 
of the articular processes may occur as a result of the compression and 
hyperflexion. In addition to the bony lesions there may be fracture 




Fig. 223. — Old compression fracture of bodies of second, third and fourth cervical vertebrae, 
twenty-eight years of age, fell down, striking head, ten years previously. 



of the intervertebral disks, and rupture of the posterior longitudinal 
ligament. 

When flexion is combined with abduction, the crushing of the body 
may take place on one side more than on the other. As a result of the 
compression of the vertebrae there is a tilting up of the spinous process 
of the vertebr.r above, so that there is a kyphosis produced in the 
dorsal region and obliteration of the curves in the lumbar region. 
When more than one vertebral body is involved, the kyphosis may be 
more marked or more rounded. 

Isolated Fractures of the Arches, Spinous Processes and Trans- 
verse Processes of the Vertebrae (Figs. 225-228). — These fractures 



FRACTURES OF THE VERTEBRAE 219 

are rare and when seen are generally the result of great direct violence, 
or are accompanied by dislocation. 

Fractures by muscular action are rare, although a fracture of a 
spinous process the result of muscular action has been reported by 
Terrier. Fractures of the arches are generally the result of direct 
violence applied to the spinous processes; and the lamella of one or 
both sides may be fractured. The loose fragments may be driven into 
the cord or cause considerable pressure upon it. A fracturing force 
severe enough to fracture the arch may produce injury to several 




ig a handspring, 

adjoining arches. Fractures of the arches are more common in the 
cervical region, and the atlas and axis are the vertebrae most frequently 
involved. 

Isolated fractures of the spinous or transverse processes are most 
frequently seen in the dorsal region and are the result of direct violence. 
The separated process ma)' be displaced anteriorly between two verte- 
brae and into the cord, although this condition is rare because the 
detached ligaments and muscles usually prevent any considerable dis- 
placement. 



220 



TREATISE ON FRACTURES 




Fig. 225. — Diagram to show types of isolated fracture of the arches, spinous and transverse processes 
of the vertebra:. 
Fig. 226. — Six lower cervical vertebra;. Fracture of the left lamina and pedicle of the fourth and 
of the lamina: of the fifth cervical vertebras. Recent. The fracture of the fourth vertebra passes through 
the lamina, through the articular surface, and through the pedicle. The fifth vertebra is fractured 
through both lamina;, completely detaching the spinous process. A hod-carrier; a man aged thirty-two 
years, fell on the round of a ladder. Death occurred six hours after the accident. Both respiration and 
heart action were labored. The phrenic nerve was pressed on by a clot of blood; and the spinal cord at 
the level of the fourth cervical vertebra appeared congested. (Mutter Museum, No. 1188.) 



Fig. 228. 




Fir.. 227. — Compression fracture of fourth and fifth cervical T 
Fig. 228. — Fran,, j the fifth and sixth cervical 1 



FRACTURES OF THE VERTEBRA 221 

Fracture-Dislocation of the Vertebrae (Figs. 229-233). — Disloca- 
tion with fracture of the vertebrae occurs in many forms. In an 
exaggerated compression fracture of the body of a vertebra asso- 
ciated with dislocation, the compressed vertebra becomes wedge- 
shaped, the upper surface slanting, and dislocation of the above verte- 
bra may take place downward and forward. This injury is generally 
produced by compression from above downward, combined with 
flexion. In dislocation combined with a diagonal fracture, the line of 
fracture may involve either the lower posterior portion of the dislo- 
cated vertebra, so that a portion of the fractured and dislocated body 
remains in its normal position, or it may involve not only the dislocated 




Fig. 229. — Dislocation of sixth cervical vertebra (Kocher). 

vertebra, but also the anterior superior portion of the vertebra below, 
in which case the fragment of the lower vertebra is carried forward 
and downward along with the dislocated vertebrae and a part of the 
intervertebral disk. In this injury the line of fracture involves two 
vertebrae and extends from behind and above downward and forward : 
The displacement in fracture-dislocations is so great at times that the 
dislocated vertebra lies on the anterior surface of the vertebra below. 
Dislocation of the upper vertebra forward and downward, combined 
with fracture of the articular processes, sometimes takes place. This 
condition so closely resembles an ordinary forward dislocation with- 
out fracture that it is almost impossible to differentiate it clinically 
except by examination with X-rays. 



222 



TREATISE OX FRACTURES 



Atypical deviations of the three mentioned forms of fracture-dis- 
location are very rare. Kocher describes two cases in which there 
were unilateral joint dislocations associated with fracture of the body 
in a downward and outward direction. Complete dislocation back- 
ward combined with fracture due to hyperextension of the neck has 
been reported; and Kocher and Wagner-Stolper mention cases of 
backward dislocation with fracture in the dorsal region. 

Kocher believes that there are three forms of force operating in 




Fig. 230. — The lower dorsal and four upper lumbar vertebra?, with portions of the three lower ribs 
of both sides. Fracture of the twelfth dorsal and first lumbar vertebrae. Partial repair. The bodies of 
the two fractured vertebrae are compressed and have coalesced. The intervertebral disk between them 
has disappeared, and pressure has forced these vertebrae backwards, so as to obliterate the vertebral 
canal. The loss of substance anteriorly has allowed the column above to bend forwards 40 degrees. 
The vertebral column is fixed in this position by permanent callus. (Mutter Museum. No. 1188.10.1 

Pic. 231. — Cervical vertebrae; luxation of the atlas. The atlas has left its articulation with the 
axis and their axes vary 45 degrees. The transverse ligament and the ligament binding the first two 
vertebras at the posterior portion of the canal were subjected to great violence. Removed from the 
body of a man who committed suicide by hanging. While recovering from an attack of mania a polit. 
he used a silk handkerchief around his neck and standing by a gas-pipe had. after attaching hand- 
kerchief, jumped up. He was found suspended by the neck, with his feet on the floor. Death ensued 
immediately. The spinal cord was completely severed. (Mutter Museum. Xo. 1187.) 

these fracture-dislocations: compressions from above downward. 
hyperflexion, and direct force. To produce the injury, one or all of 
them may l>e acting. He considers that this accounts for the relative 
frequency of dislocation with diagonal fractures in the dorsal region. 
because compression acting upon a normally flexed portion of the 
spine increases the flexion. They are rare in the lower dorsal and 
lumbar region on account of the normal lordosis, whereas isolated com- 

n fractures of the bodies of the vertebrae and dislocation-com- 

n fracture-; arc- more common in this region. 



FRACTURES OF THE VERTEBRAE 



223 



Of especial importance are the fracture-dislocations occurring in 
the two tipper cervical vertebrae. Fractures of the atlas may occur in 
its anterior or posterior arches, with or without dislocation of the 
anterior fragment and the head. Displacement generally takes place 
in all cases and is always forward. In fracture of the odontoid process 
of the axis, the process may be carried forward with the atlas if the 



V 



Fig. 232. — Fracture-dislocation of fourth cervical vertebra. Symptoms: referred pain to base 
of neck, right side; some limitation of motion. No evidence of pressure symptoms. Recovery. 

transverse ligament is not ruptured. Symptoms of pressure upon the 
cord do not take place unless dislocation occurs. These symptoms may 
be deferred for months, as in the six cases reported by Coste, Kiister 
and Phillips. 

Wood-Jones from an examination of five sets of vertebras obtained 
from bodies the result of judicial hanging, in which the knot was 



224 



TREATISE ON FRACTURES 



placed a little to the left of the chin, i.e., a submental knot, has found 
a fracture-dislocation of the axis vertebra, consisting in a separation 
of the arch of the vertebra from the body. In these cases the odontoid 
process played no part in producing death, but the posterior arch of the 
axis was broken clean off and remained fixed to the third vertebra, 
while the atlas, the odontoid process, and anterior arch of the axis 
remained fixed to die skull. This lesion is produced by the violent jerk 



Fro. ?-33- — Fracture-dislocation of bodies of eighth and ninth thoracic vertebra?. 

which throws the man's head suddenly backward and produces a fract- 
ure of the axis. In this series death was instantaneous, as the spinal 
cord was cleanly severed. 

'I he usual form of dislocation fracture of the upper cervical verte- 
brae is due generally to a fall upon the head or the falling of a weight 
upon the head while the neck is in a flexed position. Direct violence in 
the back of the neck may rarely be the etiologic factor. 

Symptoms. — Fractures of the vertebrae derive their chief impor- 
tance from the damage done to the spinal cord and nerve-trunks, which 



FRACTURES OF THE VERTEBRAE 225 

so often accompanies them. The spinal column may be said to have as 
functions : support to the trunk, upper extremities, and head; flexion, 
extension and rotation; and protection to the spinal cord which is 
essential to life and health. The symptoms may therefore be divided 
into those associated with the fracture itself, and those due to injury 
to the spinal cord and nerve roots. In addition there are certain 
special symptoms which may attend fractures at different levels. 

The symptoms associated with the fracture itself may be described 
as follows : 

Shock. — There is frequently a certain degree of shock present 
for a time after the accident. Intelligence is, however, unimpaired, 
except, perhaps, during the initial stage of shock. 

Deformity. — There is often in vertebral fractures no noticeable 
deformity. In most cases, however, there is deformity present. This 
is dependent upon the site of fracture, upon the form of fracture and 
also upon the presence or absence of dislocation. In fractures in the 
cervical and lumbar regions the normal concavity is decreased, ob- 
literated, or replaced by a kyphosis, while in the dorsal region the 
normal convexity may be increased or sharply accentuated at or near 
the seat of fracture. The most common type of deformity in the latter 
region is a marked kyphosis, caused by the spine of the vertebra above 
the one fractured, or if associated with a dislocation by the vertebra 
broken. An obliteration of the normal cervical or lumbar concavity 
or an accentuation of the dorsal convexity in cases of fracture usually 
points to a compression fracture alone or to a diagonal fracture of one 
or two vertebra with or without a dislocation. The site of injury 
may be recognized by the prominence of the spinous processes. In 
fracture-dislocations of the upper four cervical vertebra the deformity 
may best be recognized by palpation through the pharynx. In isolated 
fractures of the spinous or transverse processes or arches, there may 
be no deformity unless the fracture is accompanied by a dislocation of 
fragments. In this case there may be lateral deviation of the spinous 
processes. 

Muscular Spasm. — The muscles about the seat of fracture are 
generally at first in a state of rigidity, and attempts at movement usu- 
ally increase this rigidity, so that fixation of the neck or back occurs 
at the seat of injury. 

Pain. — This is generally present at the seat of fracture. It is in- 
creased by movement, active or passive, and by local pressure. It nay 
be absent. 

Swelling. — Near the seat of fracture there may be found some 
swelling and after a few days this may be accompanied by ecchymosis. 
These symptoms are, however, variable. 
15 



y. to rectus lateralis 

uiic. minor 
Anailomosa Kith Hypoglossal 
Anastomosis Kith pneumoaastric 
M to rectus antie.Tnajor 
, ^V. to mastoid i 
.Great auricular n~ 
-Transverse cervical m. 
■y. to Trapezius, Aug. Scap. and Rhomboid 

Supra clavicular m. 
Supra-acromial n. 

y. to levator ang 

y. to rhomboid 

^Subscapular n. 
SMdnJcaJsr -.. 



iV. to peetoralis major. 



Small internal cutaneous i 




ttatten. 



-The relation of the segment! of the spinal cord and their nerve-roots to the bodies and spines 
of the rertebr*. (Starr, from Dejerme et Thomas. Mai. d.l. Moelle Epiniere. Paris, iooj.) 



FRACTURES OF THE VERTEBRAE 227 

Mobility. — Unusual mobility may be observed at times, especially 
in fractures of the cervical region, and occasionally movable regions 
may become more or less immobile, due to spastic contracture of the 
muscles at the seat of fracture or because of the interlocking of 
dislocated fragments. 

Crepitus. — This may be present, absent, or only discernible by the 
patient. In fractures of the spinous process, crepitus can generally be 
readily elicited. In other forms of fracture, movements to' obtain 
crepitus should not be attempted, as such motions may further increase 
the dislocation of fragments and cause injury to the spinal cord. 

Symptoms Due to Injury of the Spinal Cord and Nerve-roots. — Of 
far greater importance than the damage to the vertebrae themselves is 
the injury to the spinal cord and nerve-roots. These lesions may be 
the result of the fracture or dislocation of the vertebrae, of puncture by 
fragments, of hemorrhage about or into the spinal cord or nerve-roots, 
of effusion about the cord, and later of pressure from callus forma- 
tion or degenerative changes in the cord itself. The symptoms are 
dependent upon the extent and position of the injury. The symptoms 
present generally indicate the height and nature of the lesion (Fig. 
234). The important symptoms may be grouped under disturbances 
of motion, of sensation, of reflexes, and vasomotor and trophic 
changes. The posture assumed by the patient in bed is often of great 
importance. 

Posture of Patient in Bed. — The posture of the patient in bed 
after injury to the spinal cord varies with the location of the injury. 
This is due to the fact that the muscles controlled at or below the 
lesion will be paralyzed, and those controlled by the cells just above the 
lesion will be in a state of contraction due to the irritation into* which 
their motor centres are thrown. If two centres of opposing action are 
involved, the stronger will be the predominant one, so that a position 
once assumed will be fixed and cannot be overcome involuntarily. The 
positions assumed in various lesions are as follows : 

Fifth Cervical Segment. — All motion is impossible, the arms are 
extended and relaxed. 

Sixth Cervical Segment. — Arms abducted, forearms supinated, 
wrists and fingers paralyzed (Fig. 235). 

Seventh Cervical Segment. — Forearms partially flexed, lie upon the 
body, hands pronated. Voluntary movements at wrist impossible; 
movements of shoulder and elbow can be made (Fig. 236). 

First Dorsal Segment. — Hands in position resemble a claw {main 
en griff e) ; shoulders and elbows freely movable. 

Second to Twelfth Dorsal Segments. — Paralysis of lower extrem- 
ities, no tendency to foot-drop, moderate resistance of the lower limbs 
to passive motion, tendon reflexes are exaggerated and muscles mod- 



228 



TREATISE ON FRACTURES 



erately rigid, unless there is complete destruction of the cord, when the 
muscles will be relaxed and tendon reflexes lost. 

Entire Lumbar Segments. — Thighs, legs and feet extended, and 
voluntary movement impossible. 

Lower Half of Lumbar Segments. — Thighs drawn up, legs flexed, 
unable to straighten legs or lift foot. 




Pic. 23;. — Position in lesion of spine between the fifth and sixth cervical vertebrre. The elbows 
are flexed and shoulders abducted. The position isdueto paralysis of thesubscapulans. ( After Thorburn.) 
FlC. 236. — Position in luxation of the sixth and seventh cervical vertebrae. The centre for the sub- 
scapulars is not involved. (After Kocher.) 

Sacral Segments. — Feet in extended position, foot-drop, unable to 
move feet or ankles, thighs and knees may be voluntarily moved. 

Motor Paralysis. — In injury to the spinal cord due to fractures 
or dislocations, the cord may be partially or completely severed. When 
only partial lesions are present, the symptoms will be entirely different 
from those manifested in complete disintegration of the cord. "When 
there is a complete transverse division or destruction of the cord, there 
will l>e complete paralysis below the level of the lesion, the limbs will 



FRACTURES OF THE VERTEBRA 



229 



be relaxed and flaccid, the paralysis symmetrical on both sides, and 
there will be complete loss of all tendon reflexes. In partial lesions of 
the cord there may be total paralysis below the leve 1 of the injury, with 
a condition of rigidity of the lower limbs and an increase of the tendon 
reflexes. When the cord sustains damage on one side only, hemiplegia 
of that side occurs. When the injury is bilateral, paraplegia occurs, 
and when the nerve-roots only are involved, the paraplegia is limited to 




Pig. 237. — Anaesthesia resulting from a lesion of the fifth cervical segment (Starr). 

Fig. 238. — Area of anaesthesia in a lesion involving the sixth cervical segment on the right and the 

fifth cervical segment on the left. (After Starr.) 

the muscles supplied by those nerves. The degree of paralysis may 
increase as the cord becomes involved in secondary degenerative proc- 
esses extending upwards, or it may diminish as the pathological process 
in the cord improves. 

In locating a fracture by the height of the paralysis, it should be 
recollected that the nerve-roots and branches run obliquely downward 
within the vertebral canal and do not escape af the intervertebral open- 
ing corresponding to their points of origin from the medulla. The 



230 



TREATISE ON FRACTURES 



diagram i Fig. 234) of Dejerine shows the usual relation between the 
various segments of the cord, the points of exit of the nerve-roots and 

spines and bodies of the vertebrae. 

Sensory Paralysis. — The degree and character of sensory paraly- 
sis are dependent upon the presence of complete transverse lesions, of 
partial lesions, and of injury to nerve-roots. Any destruction of the 
sensory areas in the cord will be followed by the loss of sensation — 
anaesthesia — which may be divided into tactile anaesthesia, analgesia, 




Hyperesthesia is shown 



Fig. 230 

by dotted area. ( Alter Herter. ) 
-vsia produced by a lesion of the first dorsal segment. Hyperesthesia is shown by 
dotted area. 



thcrmo-anaesthesia and loss of muscular sense or imperfect co-ordina- 
tion. Lesions of sensory roots will involve all of these sensory phe- 
nomena, whereas lesions of the cord itself, owing to the different 
-ied by the sensory nerve-fibres, make it possible for one 
form of sensation to be lost, while others are preserved. This accounts 
for the irregularity of distribution of the various forms of anaesthesia 
in partial lesions of the cord (Figs. 237-256). 

In complete transverse lesions of the cord there is complete trans- 
verse anaesthesia of the body below the segment which is destroyed. 



FRACTURES OF THE VERTEBRA 



231 



The location of the lesion in the cord may be accurately determined by 
localizing the area of anaesthesia. It must be remembered that the 
exit of the nerve- roots takes place, not at their points of emergence 
from the cord, but at a lower level as shown in Figs 243 and 244. 
Chipault gives the following rules for determining the relation of the 
segments to the spinous processes of the vertebrae: " In the cervical 




Fig. 241. — Areas of anaesthesia in fracture of the spine involving the sixth and seventh cervical 
vertebras. The lesion is just below the centre for the subscapular muscle. (After Thorburn.) 

Fig. 242. — Right-sided anaesthesia due to lesion of the fifth cervical segment, and left-sided anaes- 
thesia due to a lesion of the first dorsal segment. Note the distribution of the anaesthesia on the inner 
surface of the left arm. (After Wichmann.) 



region add one to the number of the vertebrae, and this will give the 
segment opposite to it. In the upper dorsal region add two ; from the 
sixth to the eleventh dorsal vertebrae add three. The lower part of 
the eleventh dorsal spinous process and the space below it are opposite 
to the lower three lumbar segments. The twelfth dorsal spinous proc- 
ess and the surface below it are opposite the sacral segments." 

The spinal cord terminates at the lower surface of the first lumbar 



232 



TREATISE ON FRACTURES 



vertebra. The remaining part of the spinal canal is occupied by the 
cauda equina. 

Cushing, in commenting upon the fact that lesions are found at a 
higher level than the area of anaesthesia, states that: "This is ex- 
plained by the investigations of Sherrington, who found that the cu- 
taneous area belonging to each spinal segment so overlaps those of the 
neighboring segments, and that the cutaneous branches of the posterior 
primary division of the spinal nerves anastomose so freely with each 





Figs. 243 and 244. Anesthesia produced by a lesion of the eleventh dorsal segment. Anterior and 
posterior views. (After Wichmann.) 

other, thai in no instance docs a single segment or root wholly supply 
a given area of skin (or a single muscle as well), but at least three 
(and Bruns says five) of them participate. Hence the upper border 
of anaesthesia points to a lesion of the next higher, or perhaps the 
second higher, segment than that represented by the level of anres- 
thesia. As the zone or area supplied by the upper of the affected 
segments is also supplied by the segment, or perhaps the two seg- 
ments above it. this is nol anaesthetic, but may be the seat of dimin- 



FRACTURES OF THE VERTEBRA 



233 



ished or uncertain sensations or hyperaesthesia. The lowest level of 
the intraspinal lesion corresponds to the highest level of the sensory 
disturbance." 

In complete lesions of the cord there may be irregular areas of 
anaesthesia, and there may be diminished sensation or hyperes- 
thesia. In addition there may be darting pains felt in the limbs 
when the partially paralyzed extremities are moved. The occur- 
rence of such pains is, under some circumstances, a sign of returning 
innervation, and, therefore, a sign ammm 
of improvement. In partial lesions 
the area of anaesthesia may be ob- 
lique, indicating an oblique lesion 
of the cord or a localized injury 
due to the pressure of fragments 
of bone. 

Above the area of anaesthesia, 
there is generally hyperesthesia, 
while between the two there may 
be analgesia and thermal anaes- 
thesia. This is due to the distri- 
bution of nerve-centres and often 
to the presence of a hemorrhage 
within the cord, to a subsequent 
inflammatory process that may in- 
tensify the disintegration, or to 
the formation of an extensive cica- 
trix. In unilateral lesions it will 
usually be found that there are tac- 
tile anaesthesia, analgesia, thermo- 
analgesia on the side of the body 
opposite the lesion, together with 
some hyperaesthesia of all of these 
sensations on the same side of the 
body as the lesion. 

Disturbances of Reflexes.—- 
This is a symptom of very great importance in injury to the spinal cord. 
The majority of the reflexes are known to have mechanisms in the spinal 
cord. These reflexes may be classified as : 

The Deep or Tendon Re-Rexes. — A loss of tendon reflex implies a 
destruction of sensory nerves, or of sensory reflex fibres in the cord, 
or of the motor mechanism. If it is possible to exclude a lesion of a 
nerve-trunk, the loss of a reflex implies a lesion of the spinal cord. 
The knee-jerk is lost in complete transverse lesions, and is diminished 
in partial lesions and in lesions of the second, third and fourth lumbar 




;. — Area of anaesthesia following injury 
nth dorsal segment. The area is higher 
as shown. (After Wichmann.) 



234 



TREATISE ON FRACTURES 



segments. The complete loss of the knee-jerk is generally a positive 
indication of complete destruction of the cord, and the persistence of 
its absence is always very significant of complete destruction. The 
knee-jerk may be exaggerated in partial lesions and in recovery from 
the lesions of h?ematomyelia. Ankle-clonus usually accompanies ex- 
aggeration of the patellar reflex. The plantar reflex is lost in lesions 
involving the upper three sacral segments, and in lesions above these 




Figs. 246 and 247.- 
the left side and of the < 
Starr and McBurney.) 



■Area of anaesthesia produced by a lesion of the lower two lumbar segments on 
-itire lumbar segment of the right side. Anterior and posterior views. (After 



levels it is reversed and altered to the Babinski reflex. This latter gen- 
erally is an indication of a lesion of the lateral column of the cord or 
in the motor tract. 

The Superficial or Cutaneous Reflexes. — These are of such variable 
occurrence thai their absence is of very little significance. The pres- 
ence <>f these reflexes demonstrates that the reflex are upon which it 
depends is in normal condition. The superficial reflexes of most value 
are the epigastric, abdominal, cremasteric, and plantar. 



FRACTURES OF THE VERTEBRAE 



235 



The Reflex Mechanisms Governing the Bladder and Rectum. — The 
centres controlling the mechanism of the bladder and rectum are lo- 
cated in the fourth and fifth sacral segment of the spinal cord. Re- 
tention of urine is one of the most frequent symptoms of injury to the 
cord. It is due to paralysis of the detrusor urinse muscle. In some 
cases the distention of the bladder overcomes the constrictive action 
of the sphincters and true incontinence occurs. In most cases, how- 
ever, the incontinence is one of retention. In a few recorded cases 
rupture of the bladder has resulted on account of the strong con- 
strictive action of the sphincter. In some cases there is a constant 

Fig. 248. Fig. 249. 





t " 




Figs. 248 and 249. — Anaesthesia following a lesion of the fifth lumbar segment. (After Eulenberg.) 

dribbling of urine without distention. In cases in which catheterization 
has to be frequently performed, there usually results a. cystitis with 
probably a subsequent pyelitis and nephritis. It is almost impossible to 
catheterize through months of life and not produce a cystitis, even 
though great care as to asepsis is given the withdrawal of urine. 

In lesions of the cervical and dorsal segments tympanitic disten- 



4 



236 TREATISE OX FRACTURES 

tion of the abdomen takes place with coincident constipation. This is 
later replaced by incontinence of faeces. The incontinence of faeces 
takes place without the sensation of having a bowel movement: con- 
trol is absent, due to paralysis of the anal sphincter ; when the stools 
are semi-liquid continuous evacuations are the rule. When the stools 
are formed, evacuation of the rectum may have to be accomplished 
bv digital manipulation. Disturbance in the action of the bladder and 

rectum takes place in lesions at 
Mt^k various levels and is not indica- 

tive of lesions of any particular 
^HV segments. 

Priapism is a common accom- 
paniment of injury of the cord. It 
generally appears within the first 
forty-eight hours after the injury, 
and may last several weeks. As a 
rule it disappears within a week. 
It is seen most frequently in frac- 
tures of the dorsal and upper lum- 
bar vertebrae. It seems to diminish 
jt ^^^L JtWt in Ire< l uenc y as the injury occurs 

MP ^M ^L l™ lower in the vertebral column, and 

is never seen in fractures below the 
second lumbar vertebra. Intro- 
duction of the catheter to relieve 
a distended bladder may produce 
an increase of the erection or 
cause a partial erection if none 
was previously present; seminal 
emissions are very rare. 

Trophic axd Vasomotor 
Disturbances. — Trophicchanges 
take place after fractures and dis- 
if the vertebra" accom- 
panied by injury to the cord. The 
presence of nerve-cells and fibres devoted exclusively to the con- 
trol of nutritive changes has not been definitely determined. It is 
known, however, that there are many trophic disturbances which 
result from injury to the spinal cord segments. They are very 
generally accompanied by vasomotor disturbances. The most com- 
mon trophic changes arc atrophy of muscles, bed-sores, and cys- 
titis. The atrophy of muscles is too rapid to be accounted for by dis- 
use. This atrophy is most noticeable in the flexor groups of muscles. 
Bed-sores occur mosl rapidly when there is continued pressure unre- 




FRACTURES OF THE VERTEBRAE 



237 



lieved by changes in position of the patient. They occur most fre- 
quently over the sacrum, over the great trochanters, upon the outer 
surface of the knees, and upon the heels ; in other words, at the spots 
subject to continuous pressure while lying in bed. Their ocairrence 
may be minimized by frequent changes in position, scrupulous clean- 
liness, bathing the skin and dusting it with such powders as zinc stear- 
ate, local rubbing with alcohol and alum, and by the substitution of 
the air- or water-bed for the ordinary mattress. Cystitis occurs rapidly 
after the introduction and continued use of the catheter. While it is 
doubtless true that the cystitis is due to the introduction of bacteria by 
the catheterization, the cystitis probably would not appear so soon in 




normal bladders. Catheterization should be entrusted only to those 
attendants who' realize the necessity for absolute cleanliness and con- 
scientious asepsis. 

The vasomotor disturbances are the result of angioparalysis or an 
angiospasm. In angioparalysis the arterioles dilate, the capillaries 
become distended with blood, and the parts are congested; clinically 
there is marked redness of the cutaneous or mucous surfaces, In 
angiospasm the arterioles are in a state of irritation or spasm ; there is 
less blood to the part, the capillaries are constricted, and the parts are 
pale or blue, and have usually a mottled appearance. The vasomotor 
changes are controlled by the vasomotor nerves, which are a part of 



238 TREATISE ON FRACTURES 

the sympathetic system. In angioparalysis there is usually a local 
elevation of temperature, but in angiospasm the local temperature is 
subnormal. 

Symptoms Associated with Lesions of Various Segments. — Upper 
Four Cervical Vertebra. — Death may 1)e sudden, from involvement 
of the vital centres in the medulla or from lesions of the centres of 
the phrenic nerves and consequent paralysis of respiration. Deformity 




Fig. 253. — Anaesthesia following a lesion of the second sacral segment. I After Oppenheim. Huber and 

Starr.) 
Frc. 254. — Anaesthesia following a lesion of the third sacral segment, i After Oppenheim, Huber and 

Starr. ) 

may be demonstrated by palpation of the posterior wall of the pharynx. 
In those cases which do not immediately die, there is usually a rapid 
pulse, low blood-pressure, high or subnormal temperature, pain along 
the course of the occipital nerves, pain on moving the head, which is 
held rigid, and sudden death may result from the manipulations during 
examination of the parts or from a slight jarring of the bed. 

Lower Three Cervical and First Dorsal Vertebrae. — Frac- 



FRACTURES OF THE VERTEBRAE 



239 



ture or dislocation of these vertebrae is the result of hyper flexion of the 
cervical spine, and a lesion of the cervical enlargement of the medulla 
may be produced. The symptoms of lesions involving the upper part 
of the cervical enlargement of the cord are to be differentiated from 
those seen in lesions of the lower part of the cervical enlargement. 

Upper Part of Cervical Enlargement. — Pulse rapid, temperature 
high, blood-pressure high, paralysis of arms which are relaxed at the 

Fig. 2SS- Fig. 256. 




Fig. 255. — Anaesthesia following a lesii 
Fig. 256. — Anaesthesia due to cc 



1 of the fourth sacral segment. (After Oppenheim, Huber and 

Starr.) 
lpression of the cauda equina. (After Starr and Lloyd.) 



patient's sides, anaesthesia below the deltoid area and over the shoulder- 
joint, pain in neck and shoulders, paralysis and exaggerated reflexes 
of lower extremities, retention of urine, paralysis of rectum, priapism, 
respiration diaphragmatic, trophic changes are rapid, unusual sweating 
of the entire body, and death within ten days or two weeks and often 
sooner. 

Lower Part of Cervical Enlargement. — The position of the upper 



240 TREATISE ON FRACTURES 

extremities is more or less characteristic. There is partial paralysis of 
the arms, which generally are abducted, the forearms flexed, the hands 
resting on the chest. The position is due to absence of paralysis of 
the shoulder muscles and flexors of the forearms. The anaesthesia is 
more marked on the inner side of the arms and forearms and is total in 
the hands ; it also affects the body, its upper limits being about the 
level of the nipples : above this there is hyperesthesia, which extends 
to the outer surface of the shoulders and arms. There is paralysis of 
the body and lower extremities. The reflexes of the legs may be 
absent at first and later exaggerated. Pain is present in the outer sur- 
faces of the shoulders, arms, and forearms. Priapism, retention of 
urine, and paralysis of the rectum are also present. When the lesion 
affects the first dorsal segment, there may be oculopupillary paralysis, 
contraction of the pupil, narrowing of the palpebral fissure, and retrac- 
tion of the eyeball. 

Dorsal Yertebr.e. — In injury of the dorsal segments of the cord 
there will be paralysis of the abdominal and back muscles and of the 
lower extremities. Paralysis of bladder and rectum occurs, and anaes- 
thesia about the trunk with an area of hyperesthesia above it. The 
level of the anesthesia is an indication of the site of the cord injury. 
Sherrington has shown that the level of the anesthesia is not on a level 
with the lesion of the cord, but that it is from three to four inches 
below the level of the lesion. This is due to the overlapping or anas- 
tomosis of the senson- nerve filaments, and to the circumstance that 
the intercostal nerves of one segment supply the skin directly related 
to two or at times three adjacent segments of the cord. In addition 
the sensor\- fibres entering the cord ascend to two higher segments 
before terminating. Starr reports a case in which there was a lesion 
of the eighth dorsal segment in a fracture of the sixth dorsal vertebra. 
and the line of anesthesia corresponded to the distribution of the tenth 
dorsal nerve, being three inches below the level of the injury. The 
area of hyperesthesia above that of anesthesia is due to the fact that 
centres above the segment injured are in a state of irritation. 

In those ca-es in which there is not complete destruction of the 
cord, the patients often refer to this area of hyperesthesia all sensa- 
tions coming up from the legs. Starr considers that this symptom is 
of value in differentiating complete from partial lesions of the cord. 

A combination of symptoms is occasionally present in lesions of 
one-half of the cord in the dorsal region to which has often been given 
the name of Brown-Sequard paralysis. These symptoms may. how- 
ever, he present in unilateral lesions at other levels. The symptom- 
are: (a) on the side of the lesion: paralysis with rigidity, increased 
tendon reflexc>. temporary elevation of temperature, diminished mus- 
cular sense in the leg. hyperesthesia to touch, temperature and pain up 



FRACTURES OF THE VERTEBRA 241 

to the level of the lesion, a narrow zone of anaesthesia about the body 
to touch, temperature and pain; (b) on the side opposite to the lesion: 
absence of paralysis, slight increase of reflexes, anaesthesia to touch, 
temperature, and pain up to a line passing about the body about an 
inch lower than the zone of anaesthesia on the side of the lesion. 

Lower Two Dorsal and Upper Lumbar Vertebrae. — Injuries 
to these vertebrae, as a rule, involve the lumbar enlargement of the 
cord. The lesion may involve the upper or lower part of the lumbar 
enlargement, or it may be limited to the conus terminalis or the lower 
three sacral segments. 

Complete Transverse Lesion of tlie Upper Part of the Lumbar 
Enlargement. — Total paralysis of abdominal and thigh muscles, with 
flaccidity and atrophy, reaction of degeneration and a loss of super- 
ficial and deep reflexes, paralysis without atrophy or reaction of de- 
generation in muscles of legs and feet, the legs lie extended and flaccid, 
loss of bladder and rectal control, girdle sensations and anaesthesia as 
high as Poupart's ligament, and failure of contraction of abdominal 
muscles on compression of testicle (Kocher*s reflex). When the lesion 
does not involve the upper two lumbar segments there may be an area 
of hyperesthesia on the front of the thigh and anaesthesia may be 
confined to the area corresponding to the lumber segment below these 
two. Recovery, if it occurs, is attended with permanent paralysis of 
the thighs. 

Complete Transverse Lesion of tlie Lower Part of the Lumbar 
Enlargement. — Paralysis is limited to the legs below the knees, and at 
times only the peronei group of muscles and feet are involved, atrophy 
of these muscles and reaction of degeneration, loss of bladder and 
rectal control due to relaxation of both sphincters ; anaesthesia is gener- 
ally limited to the posterior and outer aspect of the thigh, and outer 
part of the leg and foot, and, as Starr has noted, it may be limited to 
peculiar areas ; the thighs and legs are flexed, the knee-jerks may or 
may not be present ; ankle-clonus and toe-reflex are absent, and testicu- 
lar sensation is preserved. Recovery in these cases makes locomotion 
possible, by application of suitable apparatus to hold the knees and 
ankles stiff and the use of crutches, because the thigh muscles are not 
paralyzed. 

Lesions of the Conus Terminalis. — Loss of bladder and rectal con- 
trol, loss of sexual power, and anaesthesia limited to the region of the 
anus and posterior part of the scrotum in the male and posterior half 
of the labia and perineum in the female; or the area of anaesthesia may 
be heart-shaped over the region of the sacrum. 

Lower Four Lumbar Vertebrae of the Sacrum. — Fracture of 
these vertebrae may produce compression of the cauda equina. The 
symptoms of these lesions may be similar to those of injuries of the 
16 



242 TREATISE ON FRACTURES 

spinal cord itself, because the cauda equina is composed of nerve- roots 
coining from the lumbar enlargement. Fractures in this region do 
not always give the same symptoms of a complete transverse lesion of 
the lumbar enlargement, since many of the nerve-roots may escape 
injury. These nerve-roots have the power of regeneration. The symp- 
toms are loss of bladder and rectal control, anaesthesia in a heart- 
shaped area over the sacral region, buttocks or posterior portion of the 
genital regions. The symptoms may show unequal distribution. Com- 
plete recovery is possible, by operation, after these injuries. Fractures 
may produce intense pain, radiating along the course of the nerves 
injured when the lesion is partial and the nerves are lacerated; the 
location of the pain may be on a higher level than the anaesthesia and 
is often a guide to the seat of fracture. These pains are generally re- 
ferred to the peripheral termination of the compressed or lacerated 
nerves. 

While the symptoms detailed above are those seen in complete 
transverse lesions at various levels, it is probable that in partial lesions 
the symptoms will be asymmetrical. The areas of anaesthesia and the 
extent of paralysis may vary on the two sides of the body, and the 
degree of paralysis and the height of anaesthesia may increase on 
account of an increasing area of degeneration or the spreading of a 
hemorrhage around or into the cord. 

Hemorrhage in the Dura and Spinal Cord. — The blood may 
be extradural; it may be subdural (haematorrachis), or it may be in 
the substance of the spinal cord (haematomyelia). The symptoms of 
subdural hemorrhage are not always definite. They generally consist 
of pain, sharp and paroxysmal in character, along the spine and at 
times referred to the course of the nerve-trunks. These pains may be 
accompanied by muscular spasm, opisthotonos, convulsions and para- 
plegia, or by an irregular distribution of the paralysis. The paralysis 
rarely is sudden in onset, in most cases becomes complete after from 
four to six days, and persists for a period of several weeks to two 
months, when it gradually disappears. The suddenness of the onset 
of the symptoms is dependent upon the size of the vessel injured. 
Lumbar puncture will disclose hemorrhage into the spinal fluid. The 
source of the hemorrhage is usually from the venous plexus about the 
cord, and the amount of the hemorrhage is dependent upon the size of 
the vessel injured and its location. Injury to a vessel high up in the 
spinal canal probably will be accompanied by considerable hemorrhage, 
and which will be greater in amount than from vessels injured at a 
lower level. 

The Symptoms of Hemorrhage Into the Spinal Cord Itself. — The 
usual site is in the region of the fourth, fifth and sixth cervical verte- 
brae and is considered by Thorburn to be due to hyperflexion of the 



FRACTURES OF THE VERTEBRA 243 

spine in this region. When the hemorrhage takes place in the white 
substance of the cord there occurs paraplegia below the segment in- 
volved. When a hemorrhage takes place in the gray substance of the 
cord there is partial wasting of muscles and anaesthesia of the upper 
extremities with loss of some reflexes. The onset of the symptoms is 
sudden, the prognosis often fatal, and in the cases in which recovery 
takes place there is always muscular weakness due to the destruction 
of the motor neurons. 

Diagnosis. — It is not always easy to make a positive diagnosis of 
fracture of the vertebrae. In isolated fracture of the spinous or trans- 
verse processes without symptoms pointing to compression of the spinal 
cord, the diagnosis may be uncertain. Generally, however, there will 
be local pain and tenderness on pressure, some irregularity of the 
spines of the vertebrae affected, swelling of the soft parts, late ecchy- 
mosis and possibly the late appearance of symptoms of compression 
of the cord from pressure by a haematoma or exuberant callus. 
Crepitus and deformity, if they exist, are important points in diagnosis. 

In fractures of the vertebrae accompanied by lesions of the spinal 
cord, it is often impossible to determine the extent of the fracture from 
the cord symptoms. The symptoms of injury to the cord may be slight 
in severe fractures, and vice versa. It may also be impossible to de- 
termine the extent of the cord injury at once ; several days must elapse 
in some cases for the surgeon to be able to fully estimate the degree 
of injury and to determine whether the lesion is complete or partial. 
The patient should be radiographed as soon as possible, and the ex- 
tent of fracture and the degree of displacement of fragments deter- 
mined. In fracture associated with injury to the spinal cord, the im- 
portant facts to be determined are the level of the cord lesion and the 
extent of compression or destruction of the cord that has occurred. 
The level of the lesion of the cord may be determined by comparing 
the muscles paralyzed and the levels of anaesthesia with the tables 
(Fig. 234). These show the relation of the segments of the injured 
cord, and of the roots and exits of the spinal nerves to the spinal 
vertebrae, the location for sensibility and motion, the segmental locali- 
zation of the automatic centres and the superficial and deep reflexes of 
the spinal cord. 

The determination of the degree of the lesion of the spinal cord is 
not always possible. When there is any sensation in the parts below 
the lesion, such as pain, tingling, numbness, and when change in posi- 
tion of the extremities or distention of the bladder is noticeable, the 
probabilities are that the lesion is not complete. When anaesthesia is 
apparently complete below the lesion, it is sometimes possible to cause 
sensation by deep picking with a needle; in these cases the sensation 
may be referred to the area of hyperaesthesia above that of anaesthesia. 



244 TREATISE OX FRACTURES 

This is not possible if the lesion is complete. If the lesion is total the 
patella reflex is permanently lost, the paralysis of the legs is flaccid, no 
rigidity is present on passive motion, and the line of anaesthesia is 
sharply defined. In partial lesions the tendon reflexes may be primarily 
lost, but the}' later return and may become exaggerated. In complete 
lesions the superficial and deep reflexes are lost, there are greater 
trophic and vasomotor changes, priapism is present, and there is com- 
plete loss of bladder and rectal control. 

Prognosis. — In fracture of the vertebrae unaccompanied by injury 
to the spinal cord, the prognosis should be favorable not only for life, 
but also for ultimate restoration of health. The rarity of such con- 
dition without injury to the spinal cord is well known. In isolated 
fractures of the spinous or transverse processes, and in compression 
fractures of the body of the vertebrae of moderate degree without cord 
injun-. the prognosis will depend upon the subsequent development of 
excessive callus, which may produce pressure, or upon the amount of 
angulation produced by the compression of the bod}' of the vertebrae. 

The prognosis of fractures of the vertebrae accompanied by injury 
to the spinal cord is not very favorable. It will depend in great 
measure upon the severity of the symptoms presented and the degree 
of the spinal cord lesion. Many patients die from myelitis, exhaustion 
of bed-sores and cystitis. Patients do at times recover, but usually 
with considerable disability from loss of power in the legs and im- 
perfect control of the bladder and rectum. The lower the seat of 
fracture the better the chance of recovery, both as to life and function. 
In cases which finally prove fatal, life is the more prolonged as the 
site of fracture descends the spinal column. Repair of the spinal cord 
never occurs, and there is never any restoration of continuity of its 
nerve-fibres possible. The seat of the lesion is replaced by scar tissue. 
Lesions involving the spinal nerve-roots are capable of complete re- 
cover}- and regeneration of nerve-tissue. These statements should be 
carefully considered when the radiograph shows the presence of bony 
pressure combined with symptoms of complete destruction of the 
cord. In partial lesions where the spinal cord is only slightly involved, 
or where only one or two motor or sensory tract- arc involved, partial 
restoration of function may follow the operative relief of pressure. 
In cases in which the spinal lesion is an extra- or subdural hemorrhage 
or a bleeding into the cord itself, restoration of function will generally 
occur to a greater or less degree. Occasionally it may be complete. 
On this account great care should be taken to save the patient's 
Strength, and particular attention should he given to the bladder and 
rectum and to the prevention of pressure sores. 

Statistics. — Burrell reported J44 cases of fracture of the vertebrae 
with a mortality of 64.5 per tent. In the cervical region the mortality 



FRACTURES OF THE VERTEBRA 245 

was 85.7 per cent.; in the upper dorsal, 76.7 per cent.; in the lower 
dorsal, 56.1 per cent.; and in the lumbar region 50 per cent. Of the 
35.5 per cent, of recoveries, 62.2 per cent, were useful, and 37.8 per 
cent, were useless. It may be stated that in a number of Burrell's 
third series there were no cord symptoms, so that the mortality of 48 
of these cases was only 37.5 per cent. 

Statistics 
Lloyd, Samuel Operated Cases 

Cervical region : Immediate Later Lumbar region : Immediate Later 

operation operation operation operation 

Deaths 21 2 Deaths 4 4 

Recovery 2 Recovery I 6 

Improved 2 I Improved : 6 

Not improved 4 Not improved I 6 

Subsequent death... 4 3 Subsequent death... 2 



Dorsal region : Sacral region 
Deaths 23 5 Deaths 



Recovery 4 10 Recovery 1 

Improved 9 18 Improved . 3 

Not improved 6 16 Not improved 

Subsequent death... 7 16 Subsequent death... 

49 65 4 

Of these 185 operations there were only 12 improvements by 
immediate operation, and of the total there were only 24 recoveries and 
40 improvements. The number of recoveries in 82 immediate opera- 
tions was 5. With late operation there were 19 recoveries in 113 
operations. The author states that from various statistics and from 
his own experience the immediate mortality is not small, and the re- 
coveries without operation far exceed those with operation. 

Chipault, in 1894, published the results of 167 patients operated 
upon for fractures of the vertebrae; of these 12 recovered and 24 
improved. 

Thorburn reported the results of 56 cases operated upon as fol- 
lows: 38 deaths, 67.8 per cent.; 18 recovered from the injury; 2 
recovered from cord symptoms; 16 showed little improvement. 

John C. Oliver reports 57 fractures and dislocation of the vertebrae, 
50 of which developed nerve symptoms, and 7 showed no special injury. 
Of these 57 cases the involved areas were as follows : cervical region, 
23; dorsal, 18; lumbar, 10; dorsolumbar, 2; 4 cases not specified; 
deaths, 39 (68 per cent.). Of the 2T, cervical cases, 22 died (95 per 
cent.). Of the 18 dorsal cases, 10 died (55 per cent.) ; 5 were dis- 
charged as improved and 3 as cured; recoveries 16.6 per cent. Of the 



246 TREATISE ON FRACTURES 

10 lumbar cases, 6 died, i was improved, and 3 remained unimproved, 
and there were no complete recoveries. Of the 2 dorsolumbar cases, 
1 death (50 per cent.). Of the 4 in which the location was not speci- 
fied, 2 died (50 per cent.). Only 50 of the cases showed nerve symp- 
toms and 41 died (82 per cent, mortality). Of the 50 cases 8 were 
operated on; 6 died (75 per cent.); 2 were unchanged. Of the 8 
operated on: cervical, 4 — 4 deaths (100 per cent.) ; dorsal, 2 — 1 death, 
1 unchanged (50 per cent.) ; lumbar, 2 — 1 death, 1 unchanged (50 per 
cent.). Non-operated cases : mortality, cervical, 94.8 per cent. ; dorsal, 
72 per cent. ; dorsolumbar, 50 per cent. ; lumbar, 55.5 per cent. 

Treatment. — All cases of suspected fracture of the vertebrae should 
be handled very carefully to prevent the production or the increasing 
of displacement of fragments and consequent injury of the spinal 
cord. The patient should be transported, examined, and moved about 
in bed with the greatest caution. Movements made to determine the 
presence of crepitus should be avoided. 

Treatment will depend in a great measure upon the site of frac- 
ture, the portion of the vertebrae fractured, and the presence or ab- 
sence of injury to the spinal cord. In fractures of the spinous process, 
laminae or arches without symptoms of pressure on the spinal cord or 
displacement of the fragments, the treatment should consist in im- 
mobilization of the parts with a well-fitting plaster-of-Paris case. In 
compression fractures of the bodies of the vertebrae, in dislocation 
fractures without symptoms of injury to the cord, and in those cases 
in which there is deformity present at the seat of fracture, reduction 
of the fragments should be attempted by traction, combined with 
hyperextension and, after reduction, by the application of a plaster- 
of-Paris case. Hyperflexion is best obtained by horizontal suspension 
of the prone patient upon a suitable strip of stout muslin, and when 
the proper degree of hyperextension has been attained the plaster case 
should be applied. 

When a complete transverse lesion of the cord is present, the ex- 
pectant form of treatment must as a rule be followed. When there are 
symptoms of injury to the spinal cord, whether the patient is subjected 
to operative intervention or not, he should be placed upon an air- or 
water-bed. Every effort should be made to prevent the occurrence 
of pressure sores, and great care should be taken to keep the sheets 
dry, clean, free of wrinkles and bread crumbs. As soon as the sheet 
becomes moist, either from urine or faeces, it should be changed. The 
back, thighs, legs, and feet should be rubbed twice a day with alcohol 
and alum, and, if necessary, additional air rings may be placed under 
the sacrum and heels. When a pressure sore has developed, it should 
be kept dry and clean by the use of alcohol, dusting powders and dry 
dressings. All sloughs should be cut away as they develop. The 



FRACTURES OF THE VERTEBRA 247 

development of a cystitis usually follows the catheterization necessi- 
tated in retention due to paralysis. This is favored by the vasomotor 
and trophic changes which take place in the bladder walls as an accom- 
paniment of the paralysis. If possible, catheterization should not be 
performed, but the urine should be allowed to overflow into a suitable 
urinal. In those cases which require catheterization, the bladder 
should be irrigated twice daily with boric acid solution (2 to 5 per 
cent.), and a small quantity of this solution should be left in the blad- 
der. When cystitis develops, more frequent irrigations may be used. 
In all cases the patient should be given internally hexamethylenamin, 
7 grains, three times daily. Suprapubic cystostomy for drainage is 
not recommended. Great care should be taken to keep the patients dry 
and clean after each movement of the bowels. As a rule the bowel 
movements are semi-liquid and frequent. It may be necessary to 
cleanse the rectum by means of enemata or at times to empty it, be- 
cause of impaction, by means of a spoon. Tympanites may be les- 
sened by the use of ice-bags, hot-water bottles, steeps, and eserin, 
1/50 grains hypodermically. 

Operative Treatment. — Indications for and against operative 
treatment : 

(1) Operation is contraindicated in the presence of shock, or when 
high or subnormal temperature, and rapid pulse or respiration are 
present. 

(2) When there is evidence of complete transverse destruction of 
the cord. 

(3) Operation is indicated when the symptoms show partial de- 
struction of the cord, compression from a blood clot or fragment of 
bone. 

(4) It may be advisable to perform a delayed operation in appar- 
ently complete transverse lesions because the symptoms sometimes 
change and become less severe, showing that the primary symptoms 
were due to concussion or to extradural hemorrhage. 

(5) If after two 1 weeks improvement is present, operation is in- 
dicated. 

(6) When the radiograph shows pressure from displaced frag- 
ments and the symptoms point to a partial lesion of the cord, imme- 
diate operation is indicated ; when, however, the symptoms are those of 
complete destruction of the cord and the radiograph shows marked 
displacement of fragments, operation is useless. 

(7) Operation is indicated in all lesions of the Cauda equina or 
posterior nerve-roots. In these cases restoration of function should 
follow the operative restoration of continuity by suture. 

(8) Operation is indicated when the symptoms point to extra- or 
subdural hemorrhage. In these instances the symptoms have a gradual 



248 TREATISE OX FRACTURES 

onset, the paralysis is incomplete, and the areas of anaesthesia are 
irregular. 

(9) It may be argued that there are reported cases of complete 
destruction of the cord ( Harte. Munro) in which restoration of 
function has taken place after operation. It is with this in mind that 
one is often prompted to operate on apparently hopeless cases. It may 
be said, however, that the operative mortality should be considered, 
that many cases show as much improvement without operation as with 
operation, and that it is only in those cases of apparently complete 
destruction of the cord which show improvement after several weeks 
that operation is indicated. 

(10) With definite evidence of fracture or dislocation and com- 
plete bilateral circular paralysis of motion and sensation, operation is 
contraindicated. 

(11) "When the symptoms are those of compression by blood 
(extradural or subdural 1 without fracture or dislocation, do not 
operate. Perform lumbar puncture. 

(12) When the symptoms are those of compression by blood and 
fragments of bone, in which the paralysis of motion and sensation is 
not complete, circular or immediate, immediate operation is indicated; 
and, especially, if the symptoms are persistent. 

(13) Do not operate in the presence of severe shock. 

(14) Late operation is indicated in those cases in which symptoms 
of pressure are progressive, or in which the pressure is evidently due 
to the growth of callus about the seat of fracture. 

(15) Late operation should be performed when improvement has 
taken place in patients in whom symptoms of improvement are not 
progressive. When symptoms are retrogressive, operation is not in- 
dicated. 

Laminectomy. — Technic. — The details of this operation may be 
found in any of the books on operative surgery. As a general rule a 
median incision over the spinous processes at the site of fracture or 
kyphosis is the l>est. The muscles are separated from the vertebral 
column and retracted, and the laminae exposed. Care should be taken 
not to press forward any of the fragments into the cord in removing 
fragment-. These should be removed rather than elevated. Disloca- 
tion of the arches or fracture-dislocations are best reduced after the 
removal of several laminae, so that one may see that no additional pres- 
ume is produced at the point of compression. The dura will usually 
Ik.- found to be not torn. It should always be opened. Any subdural clot 
should be removed. After reducing any displacement and removing 
fragments or blood clot, the dura should be closed without drainage 
with absorbable sutures and the wound of the soft parts sutured. It is 
useless to suture the cord when it has been completely crushed trans- 



FRACTURES OF THE VERTEBRAE 



249 




250 



TREATISE OX FRACTURES 



versely. Lacerated or severe nerve-roots should l^e repaired by fine 
silk sutures. 

After-treatment. — In all cases, whether apparently hopeless or 
not. the paralysis should be treated by massage and electricity if of the 
flaccid type : when it is of the spastic type electricity will excite the 
muscles to spasmodic contracture and should not be used. Spasmodic 
contractures seen in partial lesions may lie very annoying to the 




-Piv.t'jgraphs sho 



patient. They may be partially controlled by the use of the bromides 
or chloral. When the patient complains of severe pain, especially at 
the level of the injury, the use of morphine will often be necessary. 
The general health of the patient should be promoted by fresh air. 
nourishing food, and pleasant companions. 

During the staj, r e of convalescence in those cases unassociated with 
paralysis support to the spine should be given by means of braces 
(Figs. 257-261). 



CHAPTER XI 

FRACTURES OF THE STERNUM 
Anatomy. — The sternum (Fig. 262) or breast-bone is situated in 
the middle of the anterior portion of the thorax; it joins the costal 
cartilage of the first seven ribs on each side, and articulates with the 
inner extremities of the clavicles, forming the shoulder girdle an- 
teriorly. It is formed of three parts : the manubrium, the gladiolus or 
body, and the xiphoid or ensiform process or appendix. 



Interclavicular notch 
Facet for clavicle 




Xiphoid process 



Fig. 262. — Sternum, anterior view. 

The manubrium has on its upper margin three notches : the median 
or interclavicular notch, and two lateral or clavicular notches for 
union with the sternal extremities of the clavicles. Below these are 
two additional notches to accommodate the costal ends of the first ribs. 
The manubrium is triangular in shape, with its base above. The 
gladiolus is flattened, narrow above, and has on each side a demifacet 
at its upper angle, which unites with another demifacet on the lower 
corner of the manubrium for the articulation of the cartilage of the 
second rib. Below this demifacet are additional notches for the 
cartilages of the third, fourth and fifth costal cartilages. The sixth 

251 



252 TREATISE ON FRACTURES 

and seventh costal cartilages articulate with the constricted lower end 
of the gladiolus by separate notches, the notch for the seventh being 
formed by a demi facet on the xiphoid cartilage. 

The xiphoid cartilage sometimes remains cartilaginous until ad- 
vanced life before it ossifies and becomes ankylosed with the gladiolus. 
It may be perforated, notched, or irregular in outline. 

Surface Markings. — The anterior surface of the sternum may 
be palpated throughout. The junction of the manubrium and gladiolus 
is marked by a transverse ridge at the level of the second costal carti- 
lage (Ludwig's angle). The lower portion of the sternum, the 
xiphoid cartilage, is generally depressed and is sometimes called the 
scrobiculus cordis or the " pit of the stomach." The sternoclavicular 
articulations are readily palpable. 

Statistics. — Bruns observed in 8560 cases, 17 instances (0.1 per 
cent.) of fracture of the sternum; Chudowsky in 2366 cases, 6 in- 
stances (0.25 per cent.) ; and Plagemann in 1393 cases, 5 instances 
(o.359 P er cent.). 

Etiology. — This is a rare injury, probably because the sternum is 
protected from indirect violence by being connected with the elastic 
costal cartilages and ribs. "When fracture occurs, it is usually due to 
such great violence that injury to the ribs or thoracic viscera also 
occurs. Fracture of the sternum may also be produced by violence 
which forcibly flexes or extends the spine. Thus fracture of the 
sternum or of the spine or of both together is produced. Great mus- 
cular efforts, such as occur in lifting heavy weights or in parturition, 
have been followed by this fracture. It may also be caused by direct 
violence, such as a blow of moderate force, limited to a small area, and 
by bullets. 

Varieties. — The first portion of the sternum and the last portion 
very frequently become united to the middle portion in early adult life 
by osseous union. Before this takes place there is fairly free move- 
ment possible at these points. In young patients it is therefore difficult 
to tell whether a given deformity is a dislocation or a fracture. Frac- 
ture may occur close to or at the joints. The most common site of 
fracture is near the junction of the manubrium and upper end of the 
gladiolus 1 Figs. 263 and 264). As a rule the line of fracture is more 
or less transverse. Longitudinal fracture should not be confounded 
with congenital fissure. Both are rare. The frequent irregularities of 
the ensiform cartilage should always be remembered. 

Symptoms. — The symptoms of fracture of the sternum are local- 
ized pain and tenderness, mobility, crepitus and in some cases de- 
formity 1 Fig. 265). These symptoms may be exaggerated by forcible 
respiration and by change of position. The attitude is often character- 



FRACTURES OF THE STERNUM 



253 



istic. The patient assumes a sitting position, with stooping of the 
shoulders, and a part of the weight of the shoulders is supported by 
the arms on each side of the bed. Late ecchymoses may be observed. 
As a rule the anterior periosteum or the ligament is torn, while the 
periosteum on the posterior surface is stripped up and remains intact. 
Other symptoms that may be present are dyspnoea, expectoration of 
blood, and orthopncea. 

Complications. — The importance of the injury is due rather to 
the complications that may exist than to the fracture itself. There 
may be profuse hemorrhage into the mediastinum, rupture of the lungs 




Fig. 263. — Transverse fracture of sterm 
its junction with the manubrium. Union 
costal cartilages of the second and third rib: 
(Mutter Museum, No. 1202.10.) 



m; union. The gladiolus was fractured transversely near 
has occurred with secondary changes in the bone. The 
of both sides are ossified. The ensiform appendix is miss- 



Fig. 264. — Oblique fracture of stern un 
the manubrium. The callus marking the line of fracture runs from the attachment of the third right 



union. The gladiolu 



was fractured near its junction with 
•d right 
upward 



costal cartilage obliquely downward almost to the fourth left costal cartilage and th 
tothethird. The callus is smooth and prominent. (Mutter Museum, No. 1202.) 

or pericardium, and the development of an area of suppuration about 
the seat of fracture or in the mediastinum. 

Diagnosis. — This may readily be made from the objective symp- 
toms. At times these may consist only in local tenderness, swelling, 
and ecchymosis, while in the other cases all of the symptoms above 
mentioned may be present. 

Osseous union takes place in from four to eight weeks. 

Prognosis. — The prognosis is dependent upon the presence of 
complications. In simple uncomplicated cases there should be no 



254 



TREATISE OX FRACTURES 



mortality, and union should progress without difficulty after proper 
reduction of the fragments. Gurlt records 98 cases : of these 54 were 
simple cases with 46 recoveries and 8 deaths, and 44 were compli- 
cated cases with 1 recovery and 43 deaths. Doubtless in the eight cases 
that died there was some complication 
present. 

Treatment. — Reduction of the frag- 
ments, if deformity is present, is to be 
accomplished by traction, hyperflexion. 
and direct pressure. A firm support, such 
as a sand pillow, should be placed be- 
tween the shoulders. The arms should 
then be drawn upward over the head and 
rotated outward slowly and with consider- 
able force. At the same time pressure 
over the lower end of the anterior frag- 
ment will generally result in reduction. 
This may also be accomplished by bringing 
the patient's head and shoulders over the 
end of a table and then drawing the arms 
upward and forcibly outward. Recur- 
rence of this deformity often takes 
place after reduction. The chest should 
be immobilized in an adhesive plaster 
swathe, or a firm cotton roller bandage. 
If reduction cannot be accomplished by 
these manipulative efforts, an incision 
should be made at the seat of fracture, 
and the depressed fragment raised by a 
suitable instrument. Retention may be 
made by a plate or by direct suture with 
chromic catgut or silver wire. The after- 
treatment in these case? and in those in 
which there is no deformity consists in the use of bromides or anodynes 
for a few days and locally an ice-bag. 

In the treatment of complications one should be guarded by gen- 
eral principles. When a localized area of suppuration occurs it should 
l>e promptly incised, and if its seat is the mediastinum, proper drain- 
age alongside or through the sternum should be obtained. 




CHAPTER XII 

FRACTURES OF THE RIBS AND THE COSTAL 
CARTILAGES 

Anatomy. — The ribs consist of twelve pairs and extend from the 
thoracic vertebrae outward, forward, and finally inward, terminating- in 
costal cartilages in front. They form the thoracic wall. They are 
divided into the upper seven, called true or sternal ribs, the lower five, 
false or vertebral ribs. The lower two of the latter are known as the 
floating ribs. The typical rib may be divided into the following parts : 
the head, the neck, the body. The head is the posterior enlarged end, 
next to this is the constricted neck between the head and the tubercle ; 
the latter marks the beginning of the body. Beyond the tubercle the 
body presents a rough surface, the angle of the rib. The body is 
curved on two axes, the dorsal curve extending from the head to the 
angle and beyond this the curve is forward and more gradual, ending 
in the sternal extremity which receives the costal cartilage. The ribs 
differ from each other somewhat, the first and second presenting 
marked peculiarities. The ribs increase in length from the first to 
the seventh and then decrease to the twelfth. The eleventh and twelfth 
ribs are short, slightly curved, the crests of the heads are wanting, and 
the tubercles have no articular surface. 

The costal cartilages serve to connect the ribs with the sternum. 
The upper seven ribs have a direct connection with the sternum through 
separate costal cartilages, while the eighth, ninth, and tenth have a 
common cartilage which joins the sternum in connection with the 
cartilage of the seventh rib. The costal cartilages are continuous with 
the ribs, increase in size from the first to the seventh and then decrease 
in size and length so that the eleventh and twelfth ribs have very little 
cartilaginous end. 

The articulations of the ribs with the vertebrae are divided into 
costocentral and costotransverse articulations. In the costocentral 
articulation there are the capsular ligament, the anterior costocentral 
or stellate ligament, and the interarticular ligament. In the costotrans- 
verse articulation there are the capsular ligament, the middle costo- 
transverse or interosseous ligament, the posterior costotransverse liga- 
ment, and the superior costotransverse ligament. 

The costochondral articulations are formed by the junction of the 
costal cartilages with the cup-shaped ends of the ribs. 

In the chondrosternal articulation there are the interarticular liga- 
ments, the anterior superior and inferior chondrosternal ligaments, 
the capsular ligaments, and the chondroxiphoid ligament. 

255 



256 TREATISE ON FRACTURES 

Surface Markings. — The ribs can be palpated anteriorly, later- 
ally and posteriorly as far as the edge of the erector spinal muscle. 
Occasionally the twelfth rib does not extend forward as far as the 
edge of this muscle, so that in counting the ribs one should begin 
above. The costochondral junction can be palpated, and especially so 
in persons showing a rhachitic tendency. 

Statistics. — Bruns observed in 8560 cases of fracture, 819 (9.5 
per cent.) instances of fracture of the ribs; Chudowsky in 2366 cases, 
193 ( 8.15 per cent. ) instances; and Plagemann in 1393 cases, 40 (2.S 
per cent.) instances of fracture of sternum. 

Pathology. — Fractures of the ribs are most frequently seen in 
adults and very rarely in children. This is accounted for by the great 
elasticity of the ribs in childhood. Green-stick fracture of the ribs 
doubtless occurs more frequently than statistics would lead one to sup- 
pose, and are often overlooked. In adults fractures frequently occur 
with little if any tearing of the periosteum and the symptoms are 
obscure. Fractures of the first and second ribs are unusual on account 
of their protected position behind the clavicle, and of the last two ribs 
on account of their mobility. Over-riding of fragments is impossible 
unless several adjoining ribs are broken. Angular deformity of a 
broken rib is also limited on account of its fixed position, the other ribs 
acting as splints. 

Etiology. — Fracture of the ribs may be caused by external violence 
or by muscular action. The most usual form of external violence is a 
blow, fall, kick, or some compressing force. Direct violence by driv- 
ing the rib inward causes fracture at the point of impact, and generally 
with inward displacement of the ends of the fragments: hence puncture 
of the viscera is more frequently seen in this class of violence. In- 
direct violence, by depressing the chest, has a tendency to bend the 
rib and cause a fracture beginning on the external surface. Fractures 
by indirect violence are most frequent near the angle, as this is the 
point of weakness and of greatest convexity. Fracture by muscular 
action may l;e produced by violent coughing and sneezing, or by lifting 
a heavy object. The tenth and eleventh ribs are most frequently the 
site of fracture. Pathological fractures of ribs are sometimes seen in 
general paralysis of the insane, and arc probably due to trophic changes 
in the hone which make them more friable. 

Varieties of Fracture.— Fracture of the ribs ( Figs. 266 and jo; | 
are most frequently seen involving the lateral and anterior por- 
tions, probably fracture at the angle being the most frequent. The 
lesion may involve only one rib, but. as a general rule, two or more are 
broken; and in .some forms of injury, such as a " squeeze," ribs may 
be fractured on both sides of the body. In fracture of a single rib the 
periosteum is generally not torn: while if several ribs are fractured 



FRACTURES OF RIBS AND COSTAL CARTILAGES 257 

the periosteum is torn and more or less deformity may be present. 
Fractures of the ribs may be open, or compound, but are rarely made 
so by puncture of the skin by a fragment of the rib. The wound is 
generally due to the fracturing force. 

Symptoms. — The symptoms of an uncomplicated fracture of the 
ribs are often obscure. When only one rib is fractured the symptoms 
may be limited to local tenderness and pain (Fig. 268) on pressure, 
pain on deep inspiration, a little swelling, late ecchymoses, and the 
presence of a nodule due to callus. The most common symptoms are 
local pain and tenderness on pressure, crepitus, mobility of the frag- 
ments, pain on moderate or deep inspiration and on anteroposterior 




Pig. 266. — Left rib; fracture; union. The fracture occurred 10 cm; from the sternal extremity; 
Left rib; fracture; union. The fracture occurred g cm. from the sternal extremity. Left rib; fracture) 
union. Thefracture occurred 7 cm. from the sternal extremity. (Mutter Museum, Nos. 1217.37-36-34. 

compression of the chest. The respiration is generally " catchy " or 
shallow and is due to irritation of the intercostal nerve by oedema, 
ecchymosis, callus, or fragments of bone. Ecchymosis appears after 
a few days in most cases. Swelling is generally present at the site of 
fracture and is due to bruising of the soft parts by the initial violence. 
Haemoptysis may be present when the fracture is complicated with a 
wound of the lung. 

Crepitus may be obtained by applying the finger-tips over the rib 
at each side of the suspected point of fracture and by causing alternate 
pressure (Fig. 269) ; or it may be detected by laying the palm of the 
hand over the point of tenderness while the patient coughs or the 
examiner makes firm pressure in the region of the injury with the 
17 



258 



TREATISE ON FRACTURES 



other hand. Crepitus may also be detected by auscultation. Abnormal 
mobility may be difficult to recognize on account of the normal mobility 
of the chest wall. A valuable symptom is pain caused by anteropos- 
terior compression of the chest wall (Fig. 270). The pain is always 
greater at the seat of fracture and may be referred along the course 
of the intercostal nerve (Fig. 268). Pain will also be complained of 




PlG. 267. — Rflntgenogram of healed fractures of the fourth to ninth left ribs 



at the seat of fracture when a forced inspiration is attempted, on 
i of the increased movement of the chest wall. 
Complications. — The complications of fractures of the ribs are 
those due to injury of the thoracic or abdominal contents. These com- 
plications are fairly frequent and may be as follows: 



FRACTURES OF RIBS AND COSTAL CARTILAGES 259 




Fig. 268. — Showing relation of intercostal artery, vein, and nerve to the rib. 
Fig. 269. Fig. 270. 




Fig. 269. — Method of making alternate pressure over rib near seat of fracture to determine abnormal 

mobility and pain. 

Fig. 270.— Method of making anteroposterior compression of the chest-wall. In fracture pain will be 

determined by this manipulation. 

Intrathoracic. — (a) Laceration of pleura and lung. The most 
common indication of such a lesion, is subcutaneous emphysema, first 
noted at the seat of fracture and rapidly spreading. This condition 
always denotes puncture of the lung. Instead of producing a sub- 



260 



TREATISE ON FRACTURES 




Fig. 271. — Compression injury of chest. Man caught under elevator. Injury consists of fracture 
of left fourth rib, which punctured the lung with resultant hemothorax. Note compensatory hyper- 
distention of right lung, or pneumothorax. 

Fig. 272. Fig. 273. 




Fig. 272. — Cross-section of chest . showing normal relations of intrathoracic structures to the overlying 
ribs. 
Fir.. 273. — Diagrammatic representation of complications which may occur in fracture of the ribs. 
On the left side is shown the presence of subcutaneous emphysema from injury to the lung due to fracture 
of the ribs at (A). On the right side is shown the presence of hemothorax and compression of the lung 
following a fracture of the ribs at (V) and associated injury to the right lung, (modified after Eisendrath) . 

cutaneous emphysema, the air from the ruptured lung may escape only 
into the pleural cavity, giving rise to a pneumothorax; or there may 
also be some blood im the pleural cavity in addition to the air, causing 
a haemopneumothorax (Figs. 271-273). The lung may actually be- 



FRACTURES OF RIBS AND COSTAL CARTILAGES 261 

come compressed and collapsed by large quantities of air and blood in 
the pleural sac. When the emphysematous condition extends into the 
mediastinum and the interlobular cellular tissue of the lung, the pa- 
tient's condition becomes critical, (b) Pericardial and heart injuries. 
These are very infrequent, except after very great violence. (c) 
Laceration of the intercostal artery is rather more infrequent than 
one would suppose. The subsequent hemorrhage is rarely severe 
enough to cause alarming symptoms, unless the site of fracture com- 
municates with a wound into the pleura, (d) Traumatic asphyxia. 
This condition follows compression of the chest in conjunction with 
fracture or dislocation, and is characterized by a dusky, cyanotic dis- 
coloration of the skin of the head, face, neck, and upper part of the 




Pigs. 274 and 27s. — Method of application of the adhesive plaster swathe in the treatment of 
fractures of the ribs. External splinting of this character gives entire relief from pain by splinting 
the external respiratory muscles of the chest. 

chest, accompanied by subconjunctival bulbar ecchymosis, usually 
limited to the interpalpebral space. This blueness appears immediately 
after the accident and is probably due to minute capillary extravasa- 
tions. (<?) Hernia of the lung. A few cases of this rare complication 
have been reported, notably by Wahl, Huguier, Weiss, and Volger. 
In most of the cases reported, the ribs involved were one or several 
of the first five ribs. 

Intra-abdominal. — The most frequent injuries of the abdominal 
organs seen as a complication of fracture of the ribs are rupture of the 
liver, spleen, stomach, or intestine, and laceration of the diaphragm. 



262 TREATISE ON FRACTURES 

Diagnosis. — The diagnosis may generally be made from the sub- 
jective and objective symptoms present. The most frequent are local- 
ized pain and tenderness, crepitus, swelling, and restricted respiration. 

Prognosis. — This is generally favorable in the usual uncomplicated 
costal fractures. Union occurs in three to five weeks by interosseous 
and ensheathing callus, which often leaves an irregularity because per- 
fect immobilization of the parts is impossible. When fracture of 
several adjacent ribs has taken place, union often occurs not only be- 
tween the fragments of each rib but the several ribs are united by an 
exuberant callus. Hernia of the lung may occur after much displace- 
ment or comminution of fragments. Marked dyspnoea of the pneumo- 
thorax is often a very distressing and at times fatal condition. The 
development of pleurisy, pericarditis or pneumonia makes the prog- 
nosis grave, but recovery after severe intrathoracic injuries often takes 
place. 

Treatment. — Fracture of the ribs should be treated by reduction of 
the fragments and immobilization. Reduction of fragments may best 
be accomplished by forcible inspiration and manipulation. If the ends 
of fragments are depressed, it rarely may be advisable to resort to 
incision for reduction. In the majority of cases there is very little 
deformity, but perfect reduction is impossible. Immobilization should 
aim at splinting the parts so that thoracic breathing is limited. This 
is best accomplished by the application of a circular swathe of ad- 
hesive plaster six to eight inches in width, encircling the chest with its 
centre at the seat of fracture (Figs. 274-275). The patient should be 
standing with the bands resting on the head during its application. 
One end of the plaster is applied and fixed to the side of the chest 
opposite to the fracture, and is carried around the body. Its applica- 
tion is completed at the end of a forced expiration. Before applying 
this dressing all hair should be removed from the chest. Several nar- 
row strips of adhesive plaster each overlapping the one below may some- 
times be found more comfortable. The lowest should be applied first. 
In a few cases such constriction of the chest will be contraindicated. 
especially if the patient has asthma or chronic bronchitis. In this in- 
stance the plaster may be applied half way around the chest, thus limit- 
ing motion on the side injured only. 

Another form of dressing consists in tbe application of a firm binder 
of heavy muslin carried around the thorax and pinned down the front; 
straps should be carried from its upper edge over the shoulders, like 
suspenders, to prevenl its slipping downward. This circular dressing 
should be worn at least three weeks, after which a circular cotton roller 
bandage may be applied for two more weeks. 

The intrathoracic complications demand, as a rule, no special treat- 
ment unless they produce grave symptoms. The cellular emphysema 



FRACTURES OF RIBS AND COSTAL CARTILAGES 263 

sometimes present requires no attention, as the air is soon absorbed. 
Even when great extension of the emphysema occurs, no danger is to 
be apprehended, except when it extends into the mediastinum and 
interlobular tissue of the lungs. Pneumo- and haemopneumothorax 
and pleural effusion, if of alarming degree, call for aspiration. Ex- 
treme congestion of the lungs, with accompanying grave dyspncea. 
should be relieved by venesection and the traditional treatment for 
pulmonary inflammations. 

Fractures of the Costal Cartilages 

These fractures occur most frequently near the costochondral junc- 
tion and involve usually the seventh or eighth cartilages. The partially 
ossified cartilages of the aged are more suscq>tible than those of the 
young; the changes taking place in advanced life are of a fibrinous char- 
acter, and calcification and ossification are not common. The line of 
fracture is generally transverse, excepting when the break is an exten- 
sion from a fracture of the sternum, when it may be longitudinal or 
diagonal in character. 

Etiology. — Many of these fractures are due to direct violence, 
although there are reported cases due to indirect violence and muscular 
action. 

Symptoms. — Deformity is the most constant symptom. In addi- 
tion there is localized pain and at times a soft crepitus. The displace- 
ment of the fragments generally shows the sternal one to be displaced 
inward and vertebral one outward. 

Diagnosis. — This rests mainly upon the deformity and site of the 
lesion. 

Prognosis. — Is good. Union takes place not by cartilage but by 
osseous or fibro-osseous tissue. This forms a bony callus around the 
ends of the fragments, and is a more or less similar union to that seen 
in fractures of the ribs. 

Treatment. — The treatment consists in replacement by manipula- 
tion, combined with forced inspiration. Immobilization is obtained in 
the same way as is used for fracture of the ribs. 



CHAPTER XIII 

FRACTURES OF THE CLAVICLE 

Anatomy. — The clavicle (Fig. 276) or collar-bone is shaped like an 
italic /, and is composed of a body or middle portion, the sternal and 
the acromial extremities. The inner end articulates with the sternum 
and is firmly attached to the latter by the sternoclavicular ligament and 
to the cartilage of the first rib by the costoclavicular ligament. The 
outer end articulates with the acromial process of the scapula and is 
firmly fixed to the acromial process of the scapula by the acromio- 
clavicular ligament and also to the scapula by the coracoclavicular liga- 
ment, which is composed of two parts, the trapezoid and the conoid. 
It is on account of the arrangement of the ligaments attached to the 
outer end of the clavicle that displacements of fragments do not as a 
rule occur in fracture of its outer one-fourth. 




Fie. 276. — Right clavicle, upper surface. 



Surface Markings.— The clavicle is superficial throughout its 
entire length. One can readily palpate the sternoclavicular and 
acromioclavicular joints and note the distinct S-shape of the bone and 
the junction of its two curves at its middle, where fractures most often 
occur (Fig. 277). Beneath the clavicle are the subclavian artery and 
vein, which are at times injured in fracture of the clavicle. The 
brachial plexus also lies beneath the clavicle and is separated from it by 
the subclavius muscle. Its entire anterior surface can be felt from the 
sternal to the acromial end. In thin persons the middle of the bone 
may be readily grasped so as to demonstrate the presence of crepitus. 

Statistics.— Fractures of the clavicle constitute from 14 to [6 per 
cent, of all fractures. Freeman, in 191 1, in a report of [428 cases of 
fracture treated at the Homestake Mine in Lead, South Dakota, gives 
only 4 per cent, involving the clavicle. Malgaigne shows 10 per cent. ; 
Bardenheuer 13 per cent.; Pitha, 18.7 per cent.; Bruns in 8560 frac- 
tures, 960 cases (11.2 per cent.) ; Chudowsky in 2360 fractures, 113 
cases (4.17 per cent.); Immelmann, in 4048 fractures, 40 cases (1 
per cent.), and Plagemann in 1393 fractures, 54 cases (3.87 per cent.). 
264 



FRACTURES OF THE CLAVICLE 



265 



Clavicular fractures are especially frequent during childhood; the 
mechanism which generally produces a dislocation at the shoulder-joint 
in adults, namely, a fall upon the shoulder or a force transmitted from 
a fall on the hand, causes a fracture of the clavicle during childhood. 

Etiology. — Fractures of the clavicle may be the result of direct 
violence, indirect violence, or muscular action. By far the most com- 
mon cause, however, is indirect violence. Thus in falls upon the 
shoulder, elbow, or hand, while the arm is extended and the muscles 




Pig. 277. — Palpation of clavicle; method of determining crepitus, abnormal mobility, and deformity. 

held rigid, the force of the impact is transmitted to the clavicle, which 
constitutes the only bony connection of the arm with the trunk. A 
tendency to exaggerate the curves of this doubly curved and twisted 
bone is thus produced, and the bone gives way as soon as the strain 
becomes too great. Cases have been reported by Malgaigne and others, 
in which the fracture was produced by bending of the clavicle over the 
first rib by sudden depression of the shoulder. Forcible compression 



2(5(5 TREATISE ON FRACTURES 

of the shoulders may also produce a fracture of the clavicle by indirect 
force. 

Instances of fracture of the clavicle by direct force are those in 
which the clavicle is directly struck by a blow or a falling object 
directed backward and downward or by the recoil of a rifle butt. 

Fracture by muscular action may be produced by vigorous sudden 
action, in which sudden contraction of the deltoid and pectoralis major 
muscles occurs, as in lifting heavy weights, suddenly seizing a fixed 
object when one is falling, or violently vising a tennis racquet. 




Varieties. — The outer part of the middle third is the most common 
site of fracture, but from its obliquity the line may extend into the 
outer or inner third. The frequency with which fractures occur at 
this region, as a result of indirect violence, is due to the small diameter 
of the bone and the sharpness of the curve at this point. Comminuted, 
multiple, or open fractures are rarely seen. Transverse and green-' 
stick fractures are frequent in children, with very little deformity, 
displacement of fragments, or laceration of the periosteum. 

Symptoms. — Fractures of the middle third (Figs. 278-281 ) present 
a characteristic symptom-complex. The usual deformity is produced 
by a tilting upward of the outer end of the sternal fragment while the 
inner end of the acromial fragment is carried inward underneath the 
sternal fragment. Thus the two portions of the clavicle form an angle 



FRACTURES OF THE CLAVICLE 



267 



-with its apex upward ; at times the}' may resemble a Y, or T. The 
shoulder is displaced forward, downward and inward (Fig. 282). 
The projection upward of the outer end of the sternal fragment is due 
to the pull of the sternocleidomastoid muscle and the lifting force 
exerted by the outer fragment being thrust under it. The displacement 
inward, forward and downward of the acromial fragment is due to 
the fact that the clavicle is the support which holds the scapula and the 
attached arm in its proper relation to the thorax (Fig. 283). Fracture 
of the clavicle removes this support, and, as a result, the scapula is 
rotated around the dorsolateral as- »■ 
pect of the chest, and the acromion | 
depressed, by the weight of the 
upper extremity and the action of 
the serratus magnus, the pectoralis 
major, and the rhomboideus muscle. 
Shortening of the clavicle may be 
determined by measuring from the 
acromion to the sternoclavicular 
articulation and comparing this 
with the sound side. Shortening 
is great in oblique fractures with 
overriding, and may amount to one 
or two inches. In some transverse 
and incomplete fractures angular 
deformity may be present in an up- 
ward and backward direction. In 
green-stick and subperiosteal frac- 
ture there may be no deformity. In 
all of these fractures the amount 
and the direction of the displace- 
ment are influenced by the continuance of the fracturing force, after 
rupture of the bone has occurred, and by the line of fracture. 

Displacement of fragments may be readily palpable and their out- 
lines visible in many cases. Crepitus is determined by grasping the two 
fragments or, in children, by grasping the shoulder and by movement, 
which causes the fractured ends to rub against each other. Crepitus is 
not present in incomplete and in green-stick and rarely in subperiosteal 
fracture. 

Fractures of the outer third (Figs. 284-286) come next in fre- 
quency to fractures of the middle third, and are as a rule irregularly 
transverse in direction. This displacement is dependent upon the loca- 
tion of the line of fracture. When it is in the area of the attachment 
of the coracoclavicular ligament (Fig. 287), little if any displacement 
of the fragments takes place ; but when the line of fracture is beyond 




Fig. 279. — Fracture of the middle third of the 
clavicle by indirect violence, characteristic de- 
formity. 



268 



TREATISE OX FRACTURES 



the attachment of this ligament, the inner end of the outer fragment 
may be tilted upward by the trapezius, and the outer end of the inner 




Fie. 280. — Fracture of the clavicle, -junction of the middle and inner thirds. Characteristic 
displacement of fragments. Outer end of inner fragment is displaced upward; outer fragment inward 




fragment drawn downward and inward by the attached fibres of the 
deltoid and portion of the pectoralis major muscles. Considerable 
angular displacement is possible. 



FRACTURES OF THE CLAVICLE 

CLAVICLE. 

SCAPULA 



269 



ACROMION 

PR0C63S 




HEAD of 

Humerus 



Fig. 282. — Shows typical displacement of fragments in complete fracture of middle third of 
clavicle. The inner fragment is pulled upward by the action of the sternomastoid muscle, while the 
outer fragment is carried downward, forward and inward with the shoulder. Dotted lines show 
normal position of shoulder. 







fracture of middle third of 



Fractures of the inner third (Fig. 288) are very infrequent. The 
deformity when present consists in a displacement downward and for- 



270 TREATISE ON FRACTURES 

ward of the inner end of the outer fragment, or angular distortion of 
both fragments in the same direction. Displacement is generally 
limited by the attachment of the costoclavicular ligament below and 
the sternocleidomastoid muscle above. Most fractures here are due to 
direct violence. Fig. 281 represents a case due to indirect violence — a 
fall upon the shoulder. 

The local deformity in fractures of the clavicle at its various parts 
has been described. In addition crepitus may be obtained except 
when the fragments are impacted, or widely separated, or when the 
fracture is incomplete. There is swelling and ecchymosis at the seat 
of fracture ; generally inclination of the head toward the affected side 
in fractures of the middle third, displacement to relax the sternomas- 
toid muscle, and a characteristic attitude with inability to raise the 
arm. This loss of function is due to pain, and prevents the raising of 
the hand to the head or placing the arm in marked abduction. 

In children fractures of the clavicle are often incomplete, or green- 
stick, and are unattended by deform- 
ity, crepitus, or displacement. These 
fractures are often overlooked unless 
the child complains of pain and refuses 
to move the arm voluntarily. Examina- 
tion will often detect localized tender- 
ness, swelling, and slight irregular 
deformity, generally anteriorly or up- 
ward; and in the course of a few days 
or a week there will be a circumscribed 
spindle-shaped swelling due to the 
formation of ensheathing callus. 

Fig. 2 84.-Fracture of outer end of In fractures of the OUter third W Hh- 

3£$L^^i£E&J£&Fv£ ollt deformity or displacement of frag- 
o n ccu t rs and "° dlsplacement of fra 8 ments ments, crepitus may be elicited, as a 
rule, by careful pressure on the upper 
surface of the outer fragment, while grasping the middle of the clavicle 
firmly and making motion. When crepitus cannot be elicited in this 
manner the presence of a fracture may be diagnosed by localized pain, 
ecchymosis, and swelling. Erdman considers that the diagnosis may 
be made in doubtful cases by the lessened transmission of respiratory 
sounds to points on the clavicle beyond the seat of fracture. 

Fractures near the acromial end may simulate supra-acromial dis- 
location. In green-stick, subperiosteal or incomplete fractures the 
formation of callus may simulate a syphilitic periostitis. A case has 
recently been treated by Dr. Kelly in which the fracture resulted from a 
slight fall upon the elbow in a patient having a syphilitic lesion of the 
clavicle. 




FRACTURES OF THE CLAVICLE 



271 



Complications. — Open fractures are rare except in cases in which 
the violence has been great and there are associated injuries. Com- 
plications that may occur are laceration of the brachial plexus, sub- 
clavian artery, subclavian or internal jugular veins, and puncture of 
the pleura or apex of the lung. The late complications are those due 
to pressure of fragments or excessive callus. 

Prognosis. — Union generally takes place in children in fifteen to 
twenty-one days and in adults in from twenty-one days to six weeks. 
Non-union is rare and when it does occur only a moderate degree of 
disability persists. Moderate deformity at the seat of fracture does 
not interfere greatly with the subsequent use of the arm. Impairment 
of function from the pressure of exuberant callus on the blood-vessels 
and nerves behind the clavicle is more often the result of the use of a 
large axillary pad during the treatment rather than direct pressure by 




Fig. 285. — Fracture of tip of outer end of clavicle. This partakes of the nature of a tear-fracture 

from force exerted through the acromioclavicular ligament. 

Fig. 286. — Fracture of the outer end of the clavicle. Fragments are held together by the attachments 

of the coracoclavicular ligaments. 

callus. The normal abduction of the arm may be lessened by union of 
callus to the coracoid process. 

Treatment. — Many cases of fracture of the clavicle are accom- 
panied by very little deformity. This is especially so in the subperi- 
osteal and green-stick fractures seen in the middle third in children, 
and in fractures of the outer third of the clavicle at the attachment of 
the coracoid-clavicular ligament. In these cases a simple retentive 
dressing is all that is necessary. Reduction of the deformity in green- 
stick fractures may often be readily accomplished ; when the displace- 
ment is slight, reduction is not advisable. In such cases a small pad 
over the seat of fracture held in place by adhesive plaster, and the use 
of a sling with the arm bound to the side, or the application of the 
claviculo-humeral dressing meet the indications for treatment (Figs. 
289-290). The pad placed over the site of break will retain its place 



272 



TREATISE ON FRACTURES 



well if covered with adhesive plaster with the rubber side next to the 
skin. It is in cases of complete fracture of the clavicle at the middle 
third, attended by marked deformity, that retention of the fragments 
in their correct position after proper reduction often becomes difficult. 
Fortunately the permanent deformity often resulting is more of a 
cosmetic defect than a permanent disability. 

Correction of the deformity in complete fractures of the middle 
third is attempted by grasping the arm and shoulder and endeavoring 




Fig. 287. — Drawing to show the attachments of the coracoclavicular and coraco-acromial ligaments 
and the reason for absence of displacement in fractures of the outer end of the clavicle. 

to swing the scapular backwards around the posterior aspect of the 
chest toward the median line of the back. By this " manoeuvre the 
shoulder is carried upward, outward and backward, and the outer or 
acromial fragment is brought into its normal position. At the same 
time moulding of the fragments is performed, and in most cases per- 
fect reduction of the fragments may be accomplished. The difficulty 
is in maintaining reduction until firm union has been established. 



FRACTURES OF THE CLAVICLE 



273 



The following methods of treatment are recommended : 
Dorsal Recumbency. — The flexed forearm and arm are held 
near the chest by a circular bandage. The patient is then placed 
upon a firm, level mattress, with his head raised on a pillow and turned 
toward the injured side, to relax the sternomastoid muscle; and a 
small sand-bag is placed over the acromion to hold the shoulder 
in the desired direction. The forearm may be held across the chest 
with a bandage looped around wrist and fastened to opposite side of 
the bed. This postural form of treatment in bed should be persisted 
in for from ten to fourteen days and is irksome only during the 




Fig. 288.— Fracture of the 



end of the clavicle. (Courtesy of Dr. P. G. Skillern, Jr.) 



first few days. At the end of that time the patient may be allowed 
to get up, as a rule, and continue treatment by one of the ambulatory 
methods, because the fragments show usually less tendency to dis- 
placement after muscular spasms have been lessened and the frag- 
ments surrounded by reparative exudates. Dorsal recumbency is as 
a rule recommended only to women who dislike clavicular deformity 
because they are required at times to go in public with the neck ex- 
posed. In men the deformity often seen after a broken clavicle is not 
objected to if good function is promised. 
18 



274 



TREATISE ON FRACTURES 



Sayre Dressing or Its Modifications (Figs. 289-293). — This 
fracture dressing is advisable in late adolescence and in adult life. It 
is not practicable in young children, in short people, or in women with 
large breasts. The skin of the chest should be shaved if hairy, and 

Fig. 289 Fig. 290. 




the chest, arm, and forearm thoroughly washed with soap and water, 
rubbed with alcohol, and well powdered. Especial attention should be 
given to the axilla. All apposed portions of skin should be carefully 
protected by several layers of lint or sheet-wadding. After the frag- 
ments have been completely reduced, a cuff of lint three inches in width 



FRACTURES OF THE CLAVICLE 



275 



is placed about the upper arm. Over this the end of a three-feet long 
strip of adhesive plaster, three inches in width, is passed in the form of 
a loop around the arm, care being taken that it is not so tight as to 
constrict the vessels. The elbow is drawn well back and fixed in this 
position by the plaster being carried around the entire chest from back 
to front to the anterior axillary line of the same side. The elbow is 
flexed and the forearm laid upon the front of the chest with the palm 
on the opposite breast. The second adhesive strip, three inches in 
width, with a hole cut in it for the olecranon, is then applied. Be- 
ginning on the posterior surface of the upper arm it is carried down to 
the olecranon, over the extensor surface of the flexed forearm and 
hand, and over the opposite shoul- 
der, so that the end may lie upon 
the dorsum of the scapula of the 
uninjured arm. Before fixing the 
strip over the sound shoulder and 
back, the forearm and hand should 
be drawn toward the sound shoul- 
der with a fair amount of force. 
The loop of the first strip acts as a 
fulcrum and the shoulder of the in- 
jured side is thereby carried up- 
ward, outward, and backward. A 
modification of the Sayre dressing 
is the addition of a third strip of 
adhesive plaster beginning at the 
elbow, running upward over the 
seat of fracture, and down the 
posterior part of the arm. A small 
folded piece of lint is placed be- 
tween the seat of fracture and the 
adhesive plaster. Ordinarily in 
most individuals this dressing may 
remain in place for two and a half to three weeks, after which time it 
may be replaced by a sling for the forearm and a circular bandage 
fixing the arm to the chest wall. The patient will, however, be much 
more comfortable if the dressing is renewed about every six or seven 
days and reapplied in the same manner after bathing the skin with 
alcohol or soap and water. 

The Claviculo-humeral Bandage Dressing (Figs. 294 and 
295). — In early childhood and stout individuals the Velpeau dressing 
with certain modifications is the one of choice. All apposed skin 
surfaces should be carefully protected. After complete reduction the 
elbow of the injured side is brought well to the front of the chest and 



Fig. 293 




276 TREATISE ON FRACTURES 

the hand placed upon the opposite shoulder. A roller bandage is carried 
from the scapula of the well side obliquely over the back of the injured 
shoulder, over this, down the outside of the arm, under the elbow, 
across the chest to the opposite axilla, and to the point of starting. 
After a sufficient number of turns have been made to support the arm, 
the bandage is carried around the arm and chest by circular turns from 
the elbow upward to the shoulder. This dressing is re-enforced by 
the application of a light plaster-of-Paris case (Figs. 32-34) or a 
silicate of sodium dressing. Before the dressing has set the patient 
is placed flat upon his back, the shoulders are pressed backward and 
held in this position until the dressing has hardened. In some cases a 

Fig. 294. Fig. 295. 




Figs. 294 and 29s. — Photographs to show application of claviculo-humeral bandage in fracture of 
the clavicle unattended by any great degree of deformity. The skin contact surfaces should be well 
separated by sheet-wadding before applying the bandage. 

small pad should be placed over the outer end of the sternal fragment 
before this dressing is applied. The patient is then allowed to walk 
about and, if advisable, a window may be cut in the dressing at the end 
of a week to observe the position of the fragments. In cases attended 
with considerable deformity this dressing should be worn four weeks. 

In fractures of the outer end of the clavicle attended by displace- 
ment of fragments, the most satisfactory dressing is Stimson's " figure- 
of-8," made of adhesive plaster (Figs. 296 and 297). 

Operative Treatment. — In all cases in which deformity recurs 
in spite of all measures made to maintain reduction, the seat of frac- 
ture should be exposed under strict asepsis, and delicate plate applied 
or the fragments may be held by the use of chromic catgut sutures 
after suitable drill holes have been made. A small drill may be used 



FRACTURES OF THE CLAVICLE 



277 



to pin the fragments together. If left in place it acts as a nail, and 
fixes the fragments in the corrected position. After the wound has 
been closed and a sterile dressing applied, a bandage, re-enforced by 
a plaster-of-Paris case should be applied. 




Figs. 296 and 297. — Stimson's "figure-of-8" dressing for fracture of acromial end of the clavi- 
cle. Fig. 296 shows "figure of 8" adhesive plaster, pad over seat of fracture, and wrist-sling. Fig. 
297 shows complete dressing. 

Summary of Treatment 

In green-stick fractures and when there is little displacement, a 
simple retentive dressing, such as a sling to support the entire arm and 
hand, with perhaps a pad over the seat of fracture held in position 
with a strip of adhesive plaster. The claviculo-humeral dressing is 
excellent. 

If much displacement and in women fearing disfigurement, reduc- 
tion should be followed by dorsal recumbancy, as described, to hold 
the lower angle of the scapula against the ribs for about two weeks ; 
then ambulatory treatment for about three weeks. 

In other cases ambulatory treatment by a Sayre, claviculo-humeral 
or Stimson dressing or some modification of them. 

In very troublesome fractures, subcutaneous nailing with Roberts 
drill-nail method, or operative fixation with absorbable or wire sutures 
or with a delicate steel or an aluminum plate. 

If non-operative treatment has left undesirable deformity, removal 
of prominence with chisel. 



CHAPTER XIV 
FRACTURES OF THE SCAPULA 

Anatomy. — The scapula (Fig. 298) or shoulder-blade is a large, 
flat, irregular bone forming the posterior part of the shoulder girdle. 
It articulates -with the clavicle and humerus at its outer extremity and 
rests upon the posterior surface of the thorax, being separated from it 
by muscles alone. It is a triangular-shaped bone, having two surfaces, 
the ventral and dorsal, three angles, the superior, the inferior and 
lateral, and three margins, the internal or vertebral, the external or 
axillary, and the superior. The dorsal surface is divided into two 
parts, called the supra- and infraspinatous fossae, by the spine. The 
superior border has a well-marked notch — the suprascapular notch — 
and external to this a hooked-like process extending forward and out- 
ward, the coracoid process. From the external angle there is a mod- 
erate constriction called the neck and, external to this, an expanded 
portion, the head, the outer surface of which is smooth and concave. 
This is termed the glenoid cavity and is the articular surface for the 
head of the humerus. The external process of the spine which passes 
over the neck and glenoid cavity from behind and above is a strong, 
irregular, broad process called the acromion. It contains a facet in- 
ternal to its apex for articulation with the clavicle. 

Surface Markings. — The scapula can readily be palpated, especi- 
ally in thin individuals. The borders, angle, and spine may be out- 
lined by flexing the elbow and placing the hand of the side to be ex- 
amined on the opposite shoulder (Fig. 299). The inferior angle, the 
superior angle, the vertebral and axillary lx>rders can lie felt readily, 
and the changes in their relation with the spine noted during abduction 
of the arm. The upper border cannot be so readily palpated. The 
acromion and spinous processes may be readily felt: the coracoid 
process, while not noticeable on inspection, can be readily felt a1x>ut 
one inch below the clavicle (Fig. 300). The acromion process may 
be used as a fixed point in estimating suspected shortening of the 
humerus, the external condyle being utilized for the other fixed point. 
The two upper extremities should be placed in the same relative [>osition 
and measurements l>etween these points carefully noted. 

Statistics. — Bruns, in 8560 cases of fracture, records 100 cases 

(i.l per cent.) of fracture of the scapula: Chudowsky. in 2366 cases 

of fracture, 20 cases (0.84 per cent.) ; Immelmann. in 4048 cases of 

fracture. 63 cases ( \Yn l>er cent.) : and I'lagemann. in 1393 cases of 

278 



FRACTURES OF THE SCAPULA 



279 



fracture, diagnosed by Rontgen rays, 13 cases (0.93 per cent.) involv- 
ing the scapula. 

Fracture of the scapula may occur in any part of the bone ; namely, 
the body, the superior angle, the inferior angle, the spine, the acromion, 
the neck, the coracoid process, and the rim of the glenoid cavity. 

Fracture of the Body of the Scapula — Etiology. — The body of 
the scapula is, on account of its position and mobility and its splinting 
by muscular masses, well protected against ordinary forms of acci- 
dental injury. Fracture when it does occur is usually the result of 
direct violence, as from falls, street accidents, blows upon the shoulder, 
and impacts from heavy falling objects. Severe contusion of the soft 
parts, as a rule, accompanies this form of injury. 



Coracoid process 
Acromion 




Superior angle 
Superior border 
Suprascapular notch 



I \ . 'V. \\ -Sub-scapular f os: 



Axillary border 



\\\ 4 fj;, attachmen1 



Fig. 298. — Right scapula, anterior vie 



Varieties. — The fracture ma}' be single or multiple, and the lines 
may be transverse or oblique. Comminution of fragments is frequent. 
Open fractures of the body are rare, excepting when due to gunshot or 
other penetrating wounds. Displacement of fragments may be due to 
the fracturing force or to the pull exerted by the serratus magnus and 
teres major muscles ; hence the deformity may be by angulation, over- 
riding or separation. 

Symptoms. — The symptoms consist of localized pain, tenderness 
on pressure, abnormal mobility, crepitus, ecchymosis and diminished 
function. Crepitus and increased mobility may be demonstrated by 
placing the hand of the injured side on the opposite shoulder, thereby 



2S0 



TREATISE OX FRACTURES 



making the lower angle prominent, or by placing the forearm behind 
the thorax on the injured side. 

Prognosis. — In fracture of the body of the scapula union occurs 
in three to four weeks. Accurate apposition of the fragments is not 

Fig. 299. Fig. 300. 




Fig. 299. — Method of palpation tor suspected fracture of scapula. 
Fig. 300. — Method of palpation of coracoid processes of the scapula 




Fig. ?or. — Left scapula: stellate fracture of the superior angle. Starting from a point in the spine 
3 cm. from the posterior border, fracture lines passed upward, backward to the posterior border, and 
downward. A fragment 2x5 cm. was detached from the posterior border. The fragments are well 
I the callus is abundant. (Matter Museum, Xo. 1247.) 



always possible and union occurs often with over-riding and excessive 
callus. Inflammatory processes or exostoses in the bursa may be fol- 
lowed by permanent disability. 



FRACTURES OF THE SCAPULA 281 

Treatment. — Approximation of the fragments is best produced 
by immobilization and splinting. This is accomplished by the employ- 
ment of a moulded and padded gypsum case over the scapular region, 
held in place by adhesive plaster ; and by immobilizing the entire upper 




Fig. 303. — Right scapula; comminuted fracture of the base of the acromion process; union. One 
line of fracture passed transversely s cm. from the apex of the acromion. The other passed at a right 
angle to it from its centre toward the border. Union is complete on the under surface, on the outer 
surface the fracture lines are marked by deep indentations. (Mutter Museum, No. 1247.40.) 

extremity with a firmly fitting claviculo-humeral bandage. This dress- 
ing may be re-enforced by a few turns of a gypsum bandage. 

Fractures of the Superior Angle of the Scapula (Fig. 30 1 ) — 
Etiology. — Fractures of the superior angle are very rare. Few have 



282 



TREATISE ON FRACTURES 



been observed or reported except in conjunction with fractures of the 
spine or body of the scapula. They are usually the result of direct 
violence. 

Varieties. — The lines of fracture may involve the spine or ex- 
tend into the subspinous fossa, as in that recorded by Hamilton. Dis- 
placement may occur upward due to the pull of the levator scapulre 
muscle. 

Symptoms are similar to those described for fracture of the body. 
Displacement of the fragment upward would be readily palpable. 

Treatment. — Immobilization of the arm by claviculo-humeral 
bandage after fixing the scapula by a padded gypsum splint. 




Fracture through base of acromial process of scapula. 



Fractures of the Inferior Angle of the Scapula — Etiology. — Gen- 
erally due to direct violence. Cases have been reported in which the 
fracture was the result of muscular action, as in wrestling or catching 
oneself with the hand while falling. 

The line of fracture is more or less transverse, and there is gen- 
erally displacement of the lower fragment forward and upward, due 
to the pull of the serratus magnus and teres major muscles. 

Symptoms. — Pain, tenderness on pressure, abnormal mobility 



FRACTURES OF THE SCAPULA 



283 



crepitus, displacement forward and upward of the detached lower 
angle with moderate over-riding of the fragments. Marked disability 
of the arm combined with apparent shortening of the bone measured 
from the spine to the lower angle are also present. 

Treatment. — The actual displacement may be partially overcome 
by bringing the elbow forward across the chest and fixing it here by 




Fig. 306. 

Fig. 305. — Sprain-fracture of acromial process of scapula. 
Fig. 306. — Separation of the epiphysis of the acromial process of the 



ipula. 



means of the claviculo-humeral bandage. Union occurs in three to four 
weeks. After the third week the forearm may be placed in a sling and 
the arm fixed to the chest by a circular bandage. 



284 



TREATISE ON FRACTURES 



Fractures of the Spine of the Scapula (Fig. 302) — Etiology. — 
Fractures here are more or less frequent on account of the exposed 
position of the scapular spine, and are the result of direct violence. 

Varieties. — The line of fracture may involve only a portion of 
the spine or it may cause a complete separation, involving the spine at 
the base of the acromion. 

Symptoms. — Fractures of the spine may be recognized clinically 
by tenderness on pressure, crepitus and abnormal mobility in the region 
of the spine, and some irregularity of outline. 

Treatment. — This consists in immobilization of the parts by a 
padded gypsum splint and an overlying claviculo-humeral bandage. 




Fig. 307. — Method of determining abnormal mobility and crepitus in fracture of the acromial pro- 
cess of the scapula by forced hyperabduction of the arm. 

Fractures of the Acromion — Etiology. — Fractures of the acromion 
may be the result of direct violence. They also occur in conjunc- 
tion with dislocation of the upper end of the humerus, and may 
be due to hyperabduction of the arm without dislocation. They may 
be the result of indirect violence, such as falls upon the hand or elbow 
or by the force, acting through attached ligaments, resulting in a 
sprain-fracture. 

Varieties. — The following varieties of acromial fractures may be 
distinguished: at the base of the acromion (Figs. 303 and 304) ; close 
to the point of articulation with the clavicle; sprain- fracture (Fig. 
305) ; and separation of the acromial epiphysis (Fig. 306). The two 



FRACTURES OF THE SCAPULA 



285 



centres of ossification for the acromion appear about the sixteenth year, 
and ossification is not complete until from the twenty-first to the 
twenty-fifth years. 

Symptoms. — The lesions may be obscured by absence of deformity 
and swelling of the soft parts. Flattening of the shoulder is produced 
when the acromion is fractured at its base and is due to the weight of 
the arm pulling the fragment downward and inward. In fracture of 
the tip of the process, little or no deformity is present and crepitus may 
be obtained by grasping the elbow while the shoulder is pushed upward. 
Inability to abduct the arm is generally present. Crepitus may be 
obtained by hyperabduction of the arm (Fig. 307). 

Prognosis. — Fibrous is more common than bony union, and is due 
usually to inability to obtain 
close approximation of the frag- 
ments : This is especially so in 
fractures at the base of the 
process. 

Treatment. — The indication 
for treatment is to immobilize 
the arm and at the same time 
force the head of the humerus 
well up against the scapula. 
These indications are met by 
the application of a firmly ap- 
plied claviculo-humeral bandage, 
reinforced by a few turns of a 
gypsum bandage (Fig. 308). 

If the deformity is great, the 
best results will be obtained by 
treating the patient in bed on a 
flat, firm mattress, with the arm held in marked abduction so as to 
relax the deltoid which is the displacing muscle. 

Fractures of the Neck of the Scapula — Varieties. — Fractures of 
the so-called anatomical neck that is immediately behind the glenoid 
cavity and parallel with it are practically unknown. Fractures of the 
surgical neck (Fig. 309) are of three varieties: The fracture line in 
one passes behind the coracoid process downward from the supra- 
scapular notch to the axillary border, and the coracoid process is 
separated from the body of the scapula; in the other the fracture line 
begins in front of the coracoid process, passing down to the axillary 
border, and the coracoid process remains attached to> the body of the 
scapula. 

These fractures are very rare. A third variety is that in which 




Fig. 30S.- 



-Dressing to immobilize shoulde 
ture of scapula. 



286 



TREATISE ON FRACTURES 



there is separation of the scapular epiphysis as a whole. The articular 
head includes not only the glenoid neck, but also the coracoid and 
acromion bases. Such an instance has been cited by Poland. 

Etiology. — The cause of these fractures is generally a fall or 
blow upon the shoulder. Farabeuf considers that this fracture may be 
produced by a blow upon the posterior aspect of the head of the 
humerus when there is outward rotation of the arm, thereby making 
the anterior portion of the capsule tense ; or, if the arm is directed back- 
ward, a fall upon the elbow may produce a similar result. 




gical neck of the scapula. 



Symptoms. — These consist of flattening of the shoulder promi- 
nence of the acromion, loss of voluntary motion of the arm, crepitus 
after reduction, and recurrence of the deformity when the arm is 
allowed to drop from the elevated position. The deformity consists in 
sinking of the outer fragment of the scapula with the attached humerus 
(Fig. 310). At times the cd^v of the fractured surface of the scapula 
may be felt through the axilla. When the line of fracture begins at 
the suprascapular notch, the relation of the coracoid process with the 
head of the humerus is unaltered, but when the coracoid process re- 



FRACTURES OF THE SCAPULA 



287 



mains attached to the body of the scapula these relations are changed. 
Forced elevation of the arm will often determine crepitus (Fig. 311). 

Diagnosis. — The condition should be differentiated from acromio- 
clavicular luxation and deltoid paralyses, from the drooping of the 
shoulder at times seen after reduction of dislocations of the upper end 
of the humerus, and from axillary dislocation of the head of the 
humerus. 

Treatment. — The indications in the treatment of these injuries is 
to elevate the arm and to produce counter-pressure upon the acromion 
end of the clavicle. This is best accomplished by a claviculo-humeral 
dressing, with a moderate pad in the axilla and the entire bandage 



■^ 





-Drawing to show the displacement of fragments in fracture through the neck of the scapula. 
-Method of determining crepitus and abnormal mobility in fracture of the neck of the 
scapula by forced elevation of the shoulder. 



reinforced by a gypsum case. Union takes place with a moderate 
amount of displacement of the fragments, and may be followed by 
some impairment of motion dependent upon the amount of periarticular 
callus present. 

Fractures of the Coracoid Process — Etiology. — Uncomplicated 
fractures of the coracoid process are very rare. They are most often 
seen as complications of luxation of the head of the humerus, or of 
coincident injury to the clavicle, ribs, or other portions of the scapula, 
occurring therefore from indirect or direct violence. A few cases of 
fracture by muscular action (Fig. 312), as in wringing clothes, throw- 
ing a ball, or in forced supination, have been observed. 



:» 



TREATISE ON FRACTURES 



Varieties. — The line of fracture is usually at the base of the 
process, :r h may be at the epiphyseal line, being in the latter instance 
an epiphyseal separation. Longitudinal splitting of the process has 
been reported. 

Symptoms. — In the absence of displacement of the process, the 
symptoms noted are pain, localized tenderness, crepitus, and eechymo- 
sis. Pa n - reased on deep inspiration and on elevating the arm. 
due to the pull of the pectoralis minor muscle, and also on flexion of 
the supinated forearm from the pull of the short head of the biceps 
muscle. Displacement >f Ihe : racoid process is generally limited by 
the action of the attached muscles and the coracoclavicular ligament 



- r-fc ■ - ' 

WTien the ! pr -• ..-placed downward and 

■ chiatis, the biceps, and pecto- 

The presence lent injuries of a grave 

nature will - tracture racoid 

s 

Treatment. — The ana E placed in a position of hyper- 

- nation. This 
is be>: I Velpeau bandage reinforced by a 

Fractures of the Rim of the Glenoid Cavity — Etiology. — Frac- 

I cavity are seen - illy as a com- 

n of luxation of the upper end of the humerus. They are the 



FRACTURES OF THE SCAPULA 289 

result of moderate violence acting through the head of the humerus 
either from a direct fall upon the shoulder or upon the elbow or hand, 
when the arm is in a position of hyperabduction. 

Varieties. — The following varieties have been noted: fracture 
of the inner rim of the articular surface in a longitudinal direction; 
fracture of the outer or lower border involving a part of the neck 
(v. Bruns) ; a comminuted or stellate fracture line involving the gle- 
noid cavity and the neck and part of the body (Poland, Flower). 

Symptoms. — Persistence of crepitus after a reduction of a luxation 
of the head of the humerus, and a tendency toward a recurrence of the 
luxation on the removal of a retentive dressing are significant of 
fracture of the rim of the glenoid. Other symptoms will be pain on 
motion, swelling about the joint, and ecchymosis. There may occur a 
late limitation of motion, and in some cases ankylosis of the joint, due 
to union of the fragments with the head of the humerus. A radiograph 
should help in making an early diagnosis. 

Treatment. — Immobilization with the claviculo-humeral dressing 
until union has occurred should be the line of treatment. After this 
has occurred massage and passive motion should be fairly vigorous, so 
as to prevent the formation of ankylosis. 



CHAPTER XV 

FRACTURES OF THE HUMERUS 

Anatomy. — The humerus (Figs. 313-314), one of the typical long- 
bones of the skeleton, is composed of the upper extremity, the shaft, 
and the lower extremity. 

The upper extremity is composed of the head, which is directed 
inward, upward and backward, at an angle of 130 degrees with the 
axis of the shaft, the anatomical neck, the greater and lesser tuber- 
osities, and the surgical neck. The anatomical neck is the constricted 
portion immediately beneath the head, to which the capsular ligament 
is attached. Beneath the anatomical neck there are two rough promi- 
nences, the larger or greater tuberosity being directed outward and the 
smaller tuberosity being directed inward and forward ; between these 
two is the bicipital groove. Below the tuberosities there is a marked 
constriction, the surgical neck. 

The shaft is cylindrical above and transversely expanded and tri- 
angular below, and in the lower half of the shaft there are three sur- 
faces, the antero-internal, the antero-external and the posterior. 

The lower end of the humerus changes from the three-sided form 
noted above to a flattened and broad form, and ends in the two con- 
dyles, the internal and external, which are placed in front transversely 
at the lower end of the shaft. A continuation of the axis of the 
humerus would be at a point posterior to the condyles. This is shown 
by the lateral view of the lower end of the humerus and in part ac- 
counts for the extreme flexion and limited extension possible at the 
elbow-joint. The axis of the condyles is placed somewhat obliquely 
to that of the shaft, forming an angle of 85 degrees which accounts 
for the carrying angle. The external surface of the external condyle 
forms a small blunt projection, the external epicondyle, and on the 
inner surface of the internal condyle is placed the prominent internal 
epicondyle. Between the two condyles there are two anterior and one 
posterior depressions. The former are the coronoid fossa and the 
radial fossa for the accommodation of the coronoid process and the 
head of the radius on full flexion; the latter or posterior depression, 
called the olecranon fossa, is for the olecranon process on full 
extension. The articular surface of the lower end of the humerus 
consists of die capitellum upon the external condyle, which articulates 
with the head of the humerus; and the trochlea upon the internal 
condyle, which articulates with the sigmoid cavity of the ulna. These 
290 



FRACTURES OF THE HUMERUS 



291 



two articulating surfaces of the lower end of the humerus are divided 
by a ridge. 

Surface Markings. — The head of the humerus can be felt most 
readily through the axilla. The roundness of the shoulder is due to 
the bulk of the deltoid muscles overlying the greater and lesser tuber- 
osities of the humerus, which may be felt through the muscle. Evi- 
dences of fracture of the upper end of the humerus may be 
determined by placing the fingers at the anterior edge of the deltoid 
(deltopectoral groove) with the thumb behind, and then grasping 



Greater tube 



External bicipital 



il supracondyl 



Radial fossa 

External condyle 

Capitellum 




External border 



Head 

Lesser tuberosity 



Internal border 



Anterior border 



Internal supracondylar ridge 



Internal condyle 
Trochlea 



Fig. 313. — Right humerus, front view. 

the flexed elbow with the other hand (Fig. 317) ; by making careful 
rotation, crepitus may be determined in a non-impacted fracture. 
The shaft of the bone can be readily palpated throughout its entire 
length (Fig. 318). The internal and external condyles of the humerus 
may be readily palpated (Fig. 319) ; and these two prominences may 
be used in conjunction with the tip of the olecranon in determining 
displacement of fragments in fractures at the lower end of the humerus 
or of the olecranon. In full extension a line drawn between the 



292 



TREATISE ON FRACTURES 



internal and external condyles posteriorly will touch the tip of the 
olecranon (Fig. 320). During full flexion the tip of the olecranon 
will be found below this line. 

The head of the radius may be palpated 
and felt to rotate in the dimple just below 
and anterior to the external condyle (Fig. 
321). The coronoid process may be felt 
in thin subjects by making deep pressure 
in the hollow, situated anteriorly just below 
the joint. The axis of the upper part of 
the upper extremity, or arm, forms with the 
fully extended and supinated forearm an 
obtuse angle, with its opening outwards, 
called the carrying angle (Fig. ^22). This 
angle is greater in the female than in the 
male on account of the greater width of the 
female pelvis. 

Statistics. — Von Bruns, from a study 
of 8560 cases of fracture, found the hu- 
merus involved in 866 cases (10. 1 per 
cent.) ; Chudowsky, in 2366 cases, found 
210 cases (8.17 per cent.) ; Immelmann, in 
4048 cases, found 940 cases (23.5 per cent.) 
and Plagemann, in a study of 1393 cases, 
studied by radiograms, found the humerus 
to be involved in 194 instances (13.92 per 
cent.). Of these he classifies as follows: 
Fractures of the humerus, 194 cases (13.9 per cent.) : 
(a) Of the upper end, 73 cases (5.24 per cent.) : 




Fig. 314. — Upper end of humerus 
showing cupping of epiphysis to re- 
ceive the pointed head of the dia- 
physis. (Piersol's Anatomy.) 



Fig. 3i; 



Fig. 316. 




Fig. 315. — Rontgrnogram of normal shoulder-joint 
-Rontgenogram showing normal epiphysis of upper end of humer 



FRACTURES OF THE HUMERUS 



293 




Fig. 317. — Method of determining crepitus and abnormal mobility in fracture of the upper end 

of the humerus. 
Fig. 318. — Method of determining crepitus and abnormal mobility in fracture of the shaft of the 




Fig. 319. — Method of palpation of the condyles of the humerus. 

Fig. 320. — Shows the norma] relation of the olecranon process of the ulna and of the condyles of 

humerus in full extension of the elbow. 



294 



TREATISE ON FRACTURES 



(i) Fractures of the anatomical neck 4 (a.29 

(2) Fracture of the greater tuberosity 30 (2.15 

(3) Fracture through the tuberosities 10 (0.71 

(4) Separations of the upper epiphysis 7 (0.509 

(5) Fractures of the surgical neck 22 (1.57 

(b) Of the diaphysis, 18 cases (1.29 per cent.). 

(c) Of the lower end, 103 cases (7.32 per cent.) 

( 1 ) Supracondylar fractures 43 (3.08 

(2) Supracondylo-intercondylar fractures .... 11 (0.78 

(3) Fractures of the external condyle 15 (1.07 

(4) Fractures of the internal epicondyle 18 (1.29 

(5) Separation of the lower humeral epiphysis 10 (0.71 

(6) Fractures of the cubital process 6 (0.43 



per cent.) 

per cent.) 

per cent.) 

per cent.) 

per cent.) 



per 


cent.) 


per 


cent.) 


per 


cent.) 


per 


cent.) 


per 


cent.) 


per 


cent.) 



Fractures of the I 
Varieties cf Fractures.- 
tures of the upper end of the hume- 
rus may be classified as : (1) frac- 
tures of the head; (2) fractures of 
the anatomical neck; (3) fractures 
through the tuberosities; (4) frac- 
tures (isolated) of the greater or 
lesser tuberosity; (5) separation of 
the upper epiphysis; (6) fractures 
of the surgical neck. 



per End of the Hu 
Frac- 




PlC. 321.— Palpation of the head of the radius. 
Normally it may be fell to .m.,i,- wiih the shaft on 
11 and supination of the hand. 



Fig. 322.— The carrying angle; formed by 
the deviation of the axis of the forearm from 
the humeral axis. (Davis' Applied Anatomy.) 



FRACTURES OF THE HUMERUS 



295 



Fractures of the Head of the Humerus (Fig. 323). — Fractures 
involving the head of the humerus without injury to other parts of 
the bone are extremely rare. Fractures involving the head are gen- 
erally found in conjunction with fractures of the anatomical neck or 
tuberosities, or with anterior dislocation of the humerus. Frac- 
tures of the head may be fissured fractures. The fragments may be 
impacted or displaced, and can generally only be detected by X-ray 
examination. They should be differentiated from fracture of the 
anatomical neck, subdeltoid bursitis, and sprain-fractures. Cases have 
been recorded by Gosselin and Gross, and by Malgaigne. 

Etiology. — The articular surface may be chipped off, or may be 
indented, or the line of fracture may extend out through the anatomical 
or surgical neck, or the tuberosities. These fractures are occasionally 
seen accompanying dislocation. 




Fig. 323. — Incomplete fracture of the head of the humerus. 

Fig. 3 -'4— Fracture of the anatomical neck of the humerus, with dislocation of the head into the 

axilla. The semi-circle group of arrows shows the position of the head. 

Symptoms. — Simple Assuring or even a complete separation of the 
head of the bone may be unrecognized. A radiogram should usually 
be made in injuries about the shoulder-joint. When the line of frac- 
ture extends into other parts, the symptoms present will partake of 
those seen in fractures of the various regions involved. Union is apt 
to occur with some deformity or excessive intra-articular callus and 
subsequent limitations of motion. 

Treatment. — Unless satisfactory reduction and approximation of 
the fragments can be obtained and shown to be so by radiogram, 
excision of the head should be performed. It is possible that nailing 
the head in position, as is done in the femur, may give satisfactory 
results and thus obviate excision. 



296 TREATISE OX FRACTURES 

Fractures of the Anatomical Neck. — These fractures occur ring- 
as isolated injuries are almost as rare as fractures of the head of 
the bone, except in those instances in which they are associated with 
luxation of the humerus. 

Etiology. — This fracture is seen most frequently in advanced life 
and as a result of direct violence, such as a fall upon the shoulder. The 
line of fracture is rarely limited to the anatomical neck, but generally 
involves one or both tuberosities and is frequently impacted. It is also 
occasionally seen in conjunction with luxation of the head. The upper 
fragment may not be impacted with the lower, and may lie free in the 
cavity of the joint or be in the axilla. The possibility of non-union in 
unimpacted fractures of the anatomical neck should always be remem- 
bered, as well as the resulting intra-articular callus formation which 
may lead to a marked ossifying arthritis. 

Symptoms. — Fractures of the anatomical neck (Fig. 324) are 
often difficult to distinguish, without the aid of the radiogram, from 
fractures of the surgical neck, tuberosities, or intra-articular fractures 
of the shoulder-joint. The chief symptoms are swelling, pain on mo- 
tion, loss of function, and the gradual appearance of ecchymosis within 
forty-eight to seventy-two hours. Deformity as a rule is slight, unless 
the head is dislocated into the axilla. Crepitus may be demonstrated 
in non-impacted fractures, when the upper fragment remains in the 
joint cavity, but it is difficult to differentiate the crepitus from that 
obtained in any other intra-articular fracture of the shoulder-joint. 
There is generally slight flattening of the shoulder, shortening of the 
arm. if the upper fragment is dislocated, and marked pain on rotation 
of the arm. 

Diagnosis. — This can best be determined by the radiogram. In 
all cases of injury about the shoulder-joint one should use this mean? 
of accurate diagnosis whenever possible. The condition should be 
differentiated from luxation of the humerus, from fracture through 
the tuberosities, and from fracture of the surgical neck. 

Prognosis. — The prognosis is dependent upon the age of the pa- 
tient, and upon whether the fragments are impacted. Complete reo >v- 
ery is the exception. The usual result is recovery with moderate im- 
pairment of motion, chiefly in abduction. Necrosis of the head may 
occur if detached from the shaft, although union has taken place in 
cases in which the head lias been considerably isolated. 

Treatment. — The treatment of many of these cases is simple. 
When impaction of fragments is present the arm should be supported 
by a sling, the shoulder perhaps protected by a shoulder cap, and the 
arm held to the chest wall by means of a swathe. Very gentle mas- 



FRACTURES OF THE HUMERUS 



297 



sage and passive motion should be begun very early, not later perhaps 
than on the fifth to the seventh day. When there is non-impaction 
with rotation outward of the head of the bone, attempts should be 
made to bring the line of fracture together by abduction and traction 
of the arm. The limb should be held in this position either by a suit- 
able traction or extension apparatus or by means of a triangular sup- 
port. Gentle massage should be begun at the end of the first week. 
When the head has been dislocated into the axilla and in those in- 
stances in which union does not occur in non-impacted cases with the 
head remaining in the joint cavity, excision of the capital fragment 
usually should be performed. This procedure is advised only in those 




Fie. 325.— Fracture of the humeru: 
Fig. 326. — Fractt 



through the greater tuberosity 

into the axilla, 
e of the humerus through the 



with dislocation of the head 



cases in which the patient's general health Warrants such a procedure. 
When this is inadvisable, however, a surprising amount of function 
may be observed even in the most unpromising cases. 

Fractures through the Tuberosities (Figs. 325 and 526). — These 
fractures are not as rare as fractures of the anatomical neck. Thev 
are often found in conjunction with fracture lines extending par- 
tially through the anatomical neck and are at times hard to differ- 
entiate from high fractures of the surgical neck. The line of fracture 
is often seen to begin anteriorly about the level of the anatomical neck 
and to run downward and backward through the tuberosities. Com- 
minuted fractures of the tuberosities are frequently seen. Such frac- 
tures are a common accompaniment of luxation of the head of the 
humerus. 



298 



TREATISE ON FRACTURES 



Etiology. — This variety of fracture is the result of a fall directly 
upon the shoulder or upon the elbow when the arm is in a position of 
adduction with the elbow inward and backward. Fracture by ab- 
duction is very infrequent, and impaction of fragments is the rule. 

Symptoms. — The symptoms of fracture through the tuberosities 
are swelling about the shoulder-joint, generally a moderate degree of 
shortening due to impaction of the fragments, occasionally crepitus, 
inability to lift the arm, apparent thickening of the bone, and marked 
local tenderness in the region of the tuberosities. A positive diagnosis 
can generally be made by the rontgenogram, and the differential diag- 




Fio. 327.— Fract 



of the greater tuberosity and of the surgical neck of the humerus. 



nosis from fracture of the anatomical neck, the surgical neck, or an 
isolated fracture of either of the tuberosities established. The dim- 
cult)' of taking two good X-ray plates in planes of an angle of 90 
degrees in the shoulder region somewhat impairs the value of the 
radiographic diagnosis. 

Treatment. — [f impaction of the fragments is present and the head 
of the bone in its normal position, attempts at further reduction should 
not be made. The arm should be held to the side, the forearm 
placed in a sling and the shoulder protected by a shoulder cap for two 
weeks, Idle value of the shoulder cap is not great as a fixation 



FRACTURES OF THE HUMERUS 299 

apparatus but protects the region from blows which might do harm. 
Careful massage and passive motion should be employed early. The 
late results are generally a limitation in rotation and abduction. Where 
a dislocation of the head of the humerus accompanies the fracture, 
the head may be reduced by operative means and nailed to the shaft. 
If this is not feasible, resection of the head should be performed. 

Fractures (Isolated) of the Greater or Lesser Tuberosities. — Iso- 
lated fracture of the greater tuberosity (Figs. 327 and 328) may 
or may not accompany anterior dislocation of the head of the hume- 
rus. One case has been reported by Malgaigne in which it accom- 
panied a backward dislocation of the head of the humerus. 

Statistics. — In Plagemann's statistics of 30 iso- 
lated fractures of the greater tuberosity, he dif- 
ferentiates three groups ; a tearing off of the 
greater tuberosity; a transverse or comminuted 
fracture of the tuberosity, and a tearing out of a 
small portion of its cortex. Of the first class 
the fracture was found six times in conjunction 
with a preglenoid dislocation, and eight times as 
an uncomplicated fracture; of the second class in 
four instances there was a transverse fracture of 
the upper face of the greater tuberosity, four 
times a multiple transverse fracture, and three 
times a comminuted fracture of the entire tuber- 
osity; and in the third class, in six instances there 
were portions of the cortex torn off the upper 
surface of the greater tuberosity. 

Fractures of the greater tuberosity were en- 
countered twenty 7 four times in the male and six 
times in the female. 

Etiology. — Fracture of the greater tuberosity is right fracture of the^tatli 
due either to a direct fall upon the shoulder, a fall has er °ccurred wltwight 

,. .. . , . . , ,, posterior displacement due 

upon the elbow or hand, producing at the time an to the action of the supra- 

... ,. r ,1 1 1 r,i 1 spinatus, infraspinatus and 

accompanying dislocation of the head of the hu- teres minor muscles, a deep 

, ,, ,. , ,, r ,1 j 1 t fissure lies between the 

merus, or to the direct pull of the attached supra- fragment and the head of 

... . . .. the capsular ligament. 

spinatus, infraspinatus, and teres minor muscles. Union is firm. (Mutter 
The tuberosity may be entirely detached and 
dislocated upward and outward, or it may be incompletely detached 
and held by a portion of periosteum to the shaft. In the latter in- 
stance a longitudinal fissure is seen beginning at the level of the 
anatomical neck and running downward. The fragment may be so 
separated that the long tendons of the biceps may be interposed. 
When the fragment is entirely detached it may be displaced between 




300 TREATISE ON FRACTURES 

the acromion and the head of the humerus, causing locking of the 
joint. Cases of fracture accompanying anterior dislocation of the 
humerus are often unrecognized. 

Symptoms. — Isolated fracture of the tuberosity with dislocation of 
the fragment may be recognized by the presence of crepitus when the 
arm is abducted and rotated. There is inability to rotate the arm out- 
ward, marked tenderness over the tuberosity, apparent increase in the 
anteroposterior diameter of the shoulder, and moderate projection of 
the acromion. When the fragment is not detached the only symptoms 
that may be present are localized tenderness, inability of outward rota- 
tion, and ecchymosis. When there is an accompanying dislocation of 
the head of the humerus, the presence of fracture may be overlooked. 
Some authorities maintain there is a marked liability to the recurrence 
of the dislocation of the head of the humerus when accompanied by 
fracture of the greater tuberosity. 

Diagnosis. — A diagnosis may be made from localized tenderness, 
failure of voluntary outward rotation, absence of shortening, occa- 
sional crepitus, absence of flattening of the shoulder, and the retention 
of rotation of the head of the bone with the shaft. 

Treatment. — Where the fragment remains in its normal position 
due to the attached periosteum, the only dressing required will be a 
wrist-sling, a swathe fixing the arm to the chest and wall, and a pro- 
tective shoulder cap. When the tuberosity is displaced upward and 
outward, the arm should be fixed in a position of abduction and out- 
ward rotation. When the displaced fragment tends to interpose be- 
tween the acromion and the head of the humerus, the fragment should 
be exposed and nailed in its proper place as suggested and performed 
by Keen. 

Isolated fractures of the lesser tuberosity are more infrequent than 
those of the greater tuberosity. They have been observed accompany- 
ing an anterior dislocation of the head of the humerus, a fracture of the 
greater tuberosity, or a fracture of the anatomical neck. When seen 
unaccompanied by other lesion, the fracture is generally due to forcible 
outward rotation of the arm or to sudden contraction of the subscapu- 
lars muscle. When separation of the tuberosity takes place, the inner 
edge of the occipital groove is removed, and dislocation of the lung 
tendon of the biceps muscle may occur. 

Symptoms. — Inward rotation of the humerus is impossible. Out- 
ward rotation is increased. There is generally marked tenderness 
below the coracoid process and a firm mass not moving with rotation 
of the arm, felt in the position of the small tubercle. Rardenheuer 
states that the arm tends to assume a position of outward rotation. 



FRACTURES OF THE HUMERUS 301 

Crepitus may at times be felt on forcible inward rotation of the 
humerus. 

Diagnosis. — This can be made by the inability of voluntary inward 
rotation of the arm, the presence of tenderness, and the detection of a 
firm mass and occasional crepitus just outside and below the coracoid 
process. A radiogram will settle the diagnosis. 

Treatment. — This consists in flexion of the forearm upon the arm 
to relax the biceps muscle, adduction, and inward rotation. This 
posture is maintained by a wrist-sling, a swathe binding the arm to the 
chest wall, and a protective shoulder cap. Fixation should be con- 
tinued for four weeks, and judicious massage and gentle passive motion 
begun at the end of ten days. The late results are good. 

Separation of the Upper Epiphysis. — The shape and limits of 
the upper epiphysis of the humerus may readily be seen by the accom- 
panying radiograms (Figs. 314-316). The upper epiphysis is formed 
of the head and the two tuberosities. The line of the epiphyseal 
cartilage in its inner third is the same as that of the anatomical neck, 
and the remaining portion passes outward just below the tuberosities. 
The under surface of the epiphysis is cup-shaped, deeper in its centre 
than at its periphery. 

Epiphyseal separations (Figs. 329 and 330) have been observed 
from infancy to the twentieth year of life. They occur most fre- 
quently between the age of eight and eighteen. In many cases there 
is only a separation at the line of the epiphyseal cartilage, but in a 
considerable number of cases, in addition to the separation of the 
epiphysis, there is a fracture cutting off a wedge-shaped portion of 
the upper end of the diaphysis. This remains attached to the epiphysis. 
One should remember that only after the third year is it possible to 
distinguish the entire epiphysis by radiogram on account of the three 
centres of ossification appearing at this time. 

Etiology. — Separations of the upper epiphysis of the humerus have 
been observed in infants after childbirth due to traction upon the arm, 
to inward pressure upon the outer surface of the humerus, or to injury 
from the finger of the obstetrician hooked into the axilla. The injury 
in other instances is generally the result of direct violence, as a fall 
directly upon the shoulder, or of indirect violence, as by hyperabduction 
of the arm, or by forcible outward rotation combined with traction. 
The condition may also be the result of a fall upon the elbow when 
the arm is in abduction. 

Symptoms. — In many cases there may be no gross deformity to the 
shoulder region aside from a general swelling. If the separation takes 
place with a fracture of a portion of the upper end of the diaphysis, as is 



302 



TREATISE ON FRACTURES 



seen in young children, the head of the bone may be rotated by the 
attached muscles so that the articular surface is directed downward and 
the fractured surface upward. The upper end of the diaphysis may 
assume an outward position, it may be found posterior, anterior or dis- 
located into the axilla, and its end may be felt in any of these positions. 
The anterior dislocation of the upper end of the shaft is a very common 
form of deformity (Figs. 331-335). When the end is displaced 




Fig. 329. — Drawing to show the usual character of epiphyseal separation. A portion of the diaphysis 

is usually attached to the separated epiphysis. (Made after rontgenograms of Fig. 330.) 

Fig. 330.— Separation of upper epiphysis of humerus. Note that a small portion of the edge of the 

diaphysis is attached to the epiphyses. (See Fig. 329.) 

into the axilla, it may be below the coracoid process and readily 
detected. Crepitus is generally soft in character unless a fracture 
of a portion of the diaphysis is also present, in which instance true 
bony crepitus may be elicited in the absence of impaction of frag- 
ments. Fain, disability, and ecchymosis appearing in (he course of 
several days are characteristic symptoms. Passive rotation of the 
elbow discloses absence of rotation of the head of the bone in non- 



FRACTURES OF THE HUMERUS 



303 



impacted fractures; when the latter condition is present rotation of the 
head occurs. In some cases there may be considerable stripping up of 
the periosteum which remains attached to the two fragments and 
prevents reduction. 

Diagnosis. — In making a correct diagnosis of this lesion the radio- 
gram is often invaluable. At other times it may be of little use. It 
should be used. Before the third year of life the radiogram will be of 




Fig. 331. — Separation o 
epiphyseal line and that an 
(Before reduction.) 



upper epiphysis of humerus. Note tha 
nusually large fragment of the diaphysi: 



ne of fracture begins at ths 
attached to the epiphyses. 



Fig. 332. — Same as Fig. 331, after reduction. 



little value and the diagnosis will depend greatly upon the deformity 
that may be present, localized pain, and an inability of voluntary move- 
ments. After this time of life it is of value in recognizing separations 
that have not been perfectly reduced, and in those in which there is a 
fracture of the diaphysis of the adherence of a small fragment of 
bone to the epiphysis. In some patients examined a considerable time 
after injury it is possible to diagnose a previous epiphyseal separation 



304 



TREATISE ON FRACTURES 





FlGS. 333 AND 334. — Photographs of case (Figs. 331 and 332) of separation of 
of left humerus. Fig. 333 shows upper end of diaphysis is displaced forward produci 
observed at the anterior aspect of the left shoulder. Fig 334. normal right shoulder 



upper epiphysis 
rig the swelling 
for comparison. 




335- — Photograph taken ten weeks afte 
excepting abduction 



y; .ill 111. .ti. mis .if the l.'ir 
1 is still slightly impaired. 



by the radiogram showing- new bone formation. A careful comparison 
with the radiogram of the sound shoulder is frequently essential, and 
very often radiograms taken in several planes will he necessary. Other 



FRACTURES OF THE HUMERUS 



305 



signs by which a diagnosis may be made are visible projection of the 
tipper end of the diaphysis, change in the normal axis of the humerus, 
and occasional shortening and distortion of the anterior axillary fold. 
Treatment. — In uncomplicated cases without displacement of frag- 
ments and in those in which reduction may readily be accomplished by 
means of traction, hyperabduction and manipulation, retention is best 
maintained by placing a small folded towel in the axilla, and fixing the 
arm to the chest wall by a modified Velpeau dressing. When reduction 
is difficult, a general anaesthetic, preferably nitrous oxide gas, should 
be used ; then by forced traction, hyperabduction and manipulation, re- 
duction may usually be accomplished. The arm is to be dressed with 
the modified Velpeau bandage. If a secondary radiogram shows 
partial recurrence of the deformity, the arm should be placed in a 




Fig. 336. — Oblique fracture of surgical neck of left humerus. 
Fig. 337. — Comminuted fracture of surgical neck of right hur 



position of permanent abduction and held there by a Monks splint or 
a gypsum encasement or by permanent traction with weight and pulley. 
In the last method the patient is kept in bed for several weeks. When 
reduction cannot be accomplished, owing to rotation of the epiphysis 
or to the presence of a portion of attached periosteum preventing re- 
placement, incision and subsequent reduction should be adopted. The 
line of separation should be exposed, the fragments reduced and coap- 
tation maintained by chromic catgut or fine, flexible wire sutures passed 
through the periosteum. One should avoid doing too much injury to 
the epiphyseal cartilage by the insertion of sutures, nails or screws 
through it. Serial radiograms should be made after reduction to 
ascertain whether reduction is being maintained. 

After-results. — Interference with the subsequent growth of the 
humerus from the upper end is always a possibility in diastases of 
epiphyses. In giving a prognosis this liability should always be remem- 



306 



TREATISE OX FRACTURES 



bered. After union takes place there will generally be some temporary 
reduction of abduction and rotation, which should disappear within 
three to four months. 

Fractures of the Surgical Neck (Figs. 336-338). — In this group 
of fractures are included those occurring between the epiphyseal line 




Fig. 338. — Humerus, left; fracture of the surgical neck; union. The fracture passed immediately 
below the condyles and through the lower portion of the anatomical neck. The lower fragment was 
drawn to the inner side and has united in a position of outward rotation; an irregular opening leads 
through the callus in the anterior surface to the head. The union is firm. (Mutter Museum. No. 
1262. IS.) 

Fig. 339. — Method of determining shortening in fracture of the humerus by measuring from the 
acromion process of the scapula to the external corMyle of the humerus, and comparison with the same 
measurement of the other arm. 



and the attachment of the greater pectoral muscle. The level of the 
fracture line is subject to considerable variation; it may extend up- 
ward into the head of the bone as seen in comminuted fractures, or 
it may descend to a lower level than the upper edge of the attached 
pectoral muscle, as in oblique fractures. The line of fracture may be 
transverse, oblique, spiral, or comminuted in character. The frag- 



FRACTURES OF THE HUMERUS 



307 



ments may be impacted or non-impacted. In Plagemann s 22 cases 
the lines of fracture were: transverse in 10 instances, oblique in 3, 
spiral in 2, and in 7 cases there was a bending fracture with the break- 
ing off of a three-cornered piece from the cortex of the humerus. The 
spiral fractures were found especially in the young, the oblique and 
bending fractures in strong men, while the transverse fractures were 
observed at all ages. Fractures in this area are considered by many 
authorities to occur in the adult as a result of such violence as in chil- 




FlG. 340. — Fracture of humerus through surgical neck. The line of fract 

and low. 
Fig. 341. — Drawing to show the displacement of fragments in Fig. 340, and th. 
determine the character of the displacement. 



regularly transverse 
uscles which 



dren produces an epiphyseal separation. While this may be partially 
so attention is directed to the many fractures of the surgical neck 
occurring during childhood, and in which there is no lesion of the 
epiphyseal cartilage. Comminution and associated fractures of the 
tuberosities are frequently seen. 

Etiology. — The fracture may result from falls upon the lateral or 
anterior aspect of the shoulder, from a blow directed downward upon 
the upper arm when the latter is in a position of abduction, from hyper- 
abduction with leverage against the acromion process, by falls upon 
the hand or elbow and rarely by muscular action. 



308 TREATISE ON FRACTURES 

Symptoms. — In fractures of this variety there are localized pain, 
tenderness, complete or almost complete inability to use the arm, swell- 
ing, and effusion of blood in the tissues. In impacted fracture, there is 
generally some thickening of the bone at the seat of fracture, due in 
many cases to comminution of fragments, and flattening of the 
shoulder externally : the arm is held supported by the other hand, and 
is generally kept close to the side. There may be moderate deformity 
at the seat of fracture due to slight displacement of the upper end of 
the lower fragment inward, and slight internal angulation. The short- 
ening is generally slight and is dependent upon the degree of impaction. 
Rotation of the elbow shows coincident rotation of the head of the 

humerus. In non-impacted frac- 
tures in addition to the local signs 
of fracture there is often marked 
shortening (Fig. 339), as meas- 
ured from the tip of the acromion 
process to the external condyle, 
and the head of the bone fails to 
rotate with rotation of the shaft 
and elbow. The deformity may 
be slight or extensive. When this 
is present the upper fragment is 
generally abducted and rotated 
outward, due to the pull of the 
muscles attached to the tuberosi- 

Fir,. 342. — Method of reduction of fragrments lui^-iwoj 

!n fr tonTn.?m^ni S uKt l ion neck °' the humerus by tl " es > or '* I1iav ^ Je rotated inward. 

upward and forward: while the 
upper end of the lower fragment is drawn inward, upward and for- 
ward by the pull of the pectoralis major, teres major and latissimus 
dorsi muscles (Figs. 340 and 341). The upper end of the lower 
fragment may, however, be displaced upward and outward by the pull 
of the deltoid muscle, in those cases of oblique fracture in which the 
line of fracture is from without, running inward, and downward. 
Abduction of the elbow is constant as a rule, and in some cases may 
resemble the position assumed in interior dislocations of the head 
of the humerus. Crepitus is generally obtainable in all cases of non- 
impacted fractures after reduction has been accomplished, and in most 
cases before reduction has been attempted. Tn all non-impacted frac- 
tures there is a marked depression at the insertion of the deltoid muscle. 
The exact line of fracture and the dislocation of the fragments may 
readily be determined by the radiogram. 




FRACTURES OF THE HUMERUS 



309 



Diagnosis. — In the ordinary case diagnosis of fracture of the sur- 
gical neck is generally made without difficulty. In impacted fractures 
the diagnosis will be determined by the presence of localized pain, 
swelling, thickening about the site of the suspected fracture, ecchy- 
mosis, inability to use the arm, the presence of moderate deformity, 
and the radiogram. In non-impacted fractures the diagnosis will be 
made from localized signs of fracture plus crepitus, abnormal mobility, 
characteristic deformity, shortening, and the failure of the head of the 
bone though in its normal position to rotate with rotation of the elbow 
and shaft. The radiogram of course acts as contributory evidence of 
a fracture. Fracture of the surgical neck may be differentiated from 
dislocation of the head of the humerus by the presence of the head of 



Fig. 343- 





Fig. 343. — Dressing for fracture of the surgical neck of the humerus. After reduction of the frag- 
ments, the arm should be kept away from the chest wall by a moderately thick pad, the forearm sup- 
ported by a wrist-sling, and the shoulder region protected by a shoulder cap. 

Fig. 344. — Shows completed dressing for fracture of the surgical neck of the humerus. 



the bone in the glenoid cavity, by crepitus, and the other characteristic 
signs of fracture. High fractures of the surgical neck are often mis- 
taken for fractures of the anatomical neck. 

Complications. — These are injury to the axillary vessels or the 
brachial plexus, empalement of the muscles and at times the skin by 
sharp fragments, and rupture of the tendon of the biceps muscle. These 
complications are, as a rule, rare. 

Treatment. — The form of treatment of fractures of the surgical 
neck of the humerus is dependent in a great measure upon the occurrence 
or non-occurrence of impaction of fragments. 

In impaction of fragments, in which the radiogram shows little 
displacement and slight mal-alignment, the best results will be obtained 



310 



TREATISE ON FRACTURES 

Fig. 345. Fig. 346. 




% 





Fig. 348. 

.5. — Spiral fracture of shaft of humerus. 
Fir,. 346.— Irregular transverse fracture of the shaft of the humerus. Reduction and immobil- 
ization have been faulty, so that union has occurred with marked deformity, angularity and over-rid- 
ing. Note the extensive callus which has been produced, not only at the seat of fracture, but also for 
a long distance away, due to the stripping up of the periosteum. 

PlG. 347. — Transverse fracture of middle of shaft of humerus. 
FlG. 348. — Oblique fracture of shaft of humerus with over-riding and angular deformity. 

probably by avoiding separation of fragments and using a wrist-sling, 
a small axillary pad, a circular swathe binding the arm to the chest, 



FRACTURES OF THE HUMERUS 



311 



and a protective shoulder cap. Gentle massage and passive motion 
should be begun at the end of the third or the fourth day and im- 
mobilization continued for three to four weeks. 

In non-impacted fractures the line of procedure and form of 
treatment are entirely different. The best results are obtained by 
complete reduction and apposition of the fractured ends. In many 
instances this can be accomplished by traction and manipulation alone 
(Fig. 342) during thorough 
muscular relaxation obtained 
under general anaesthesia. After 
reduction three forms of reten- 
tion are favorable. In the trans- 
verse fractures, reduction is not 
as a rule followed by recurrence 
of deformity if proper retentive 
apparatus is applied. It is de- 
sirable to use an axillary pad to 
control the inward pull of the 
greater pectoral and broad dorsal 
muscles, to employ a wrist-sling, 
to fix the arm to the chest wall 
with a swathe, and perhaps to 
protect the region with a shoul- 
der-cap splint (Figs. 343 and 
344) . The last is often unneces- 
sary and sometimes undesirable. 
The cases in which this dressing 
will not prevent recurrence of 
deformity are as a rule the 
oblique, spiral, and multiple 
fractures. For these, ambula- 
tory treatment with the use of 
vertical traction is sometimes 
sufficient but may be inefficient FlG . 
because it is seldom constant. A 
considerable number of these cases are best treated by recumbency in 
bed and the application of continuous traction apparatus in the abducted 
position. There are, however, a small number of these fractures in 
which, for various reasons, ideal results cannot be obtained by either of 
these methods ; in these it is wise to adopt open operation and obtain 
anatomical approximation and fixation by means of a metal plate or 
perhaps by the absorbable catgut mat of Straus plate. The ideal in- 
cision is made along the anterior border of the deltoid muscle. 




. 349. — Long oblique fracture of 6haft of humerus. 



312 



TREATISE ON FRACTURES 



Many fractures at the upper end of the humerus may be satisfac- 
torily treated by simple restraint of motion induced by carrying a 
broad strip of adhesive plaster or bandage once around the arm and 
chest and placing the wrist in a narrow sling. Other fractures in this 
region may need in addition the hollow of the axilla filled with a folded 
napkin or thin compress and the arm secured against the chest with 
the elbow carried a little forward. By these dressings the thorax acts 



Fig. 350 




ment of the pectoralis major muscle. 



the shaft of the humerus. (See Fit 
to demonstrate the action of the muscles 
the fragments in fracture belc 



as a splint. In such cases the shoulder cap of gypsum or other rigid 
material is usually unnecessary. 

After-results. — These are generally good. Impairment of full 
motion persists for a time, but can be overcome by persistent massage 
and passive motions. In some cases there will be permanent impair- 
ment of motion due to exuberant callus, to failure to properly reduce 
and maintain reduction, to comminution of fragments, and to involve- 
ment of muscles in projecting sharp fragments. Pseudarthrosis is 
infrequent, and delayed union when seen is not generally permanent. 



FRACTURES OF THE HUMERUS 313 

Fractures of the Shaft of the Humerus. 

Varieties of Fractures (Figs. 345-349). — Fractures of the shaft 
of the humerus include all fractures involving the diaphysis between the 
insertion of the pectoralis major muscle and the upper limits of the 
supracondylar ridges. These fractures are as a rule complete and 
closed in character. Occasionally an incomplete fracture of the shaft 
is observed in children. Plagemann, in the 18 cases of his statistics, 
gives the lines of fracture as follows : 1 1 transverse, 2 oblique, 3 spiral 
and 2 bending fractures with the separation of a rhomboidal piece of 
bone. Longitudinal fractures are extremely rare, but have been re- 
ported by Gurlt, Cloquet and Kronlein. 

Etiology. — Fractures of the shaft are the result of external vio- 
lence or muscular action. Fractures by external violence result from 
a direct blow, a fall upon the arm against some object, by crushing 
accidents and collision of vehicles. Fractures in these regions by 
indirect violence such as a fall upon the elbow or hand are extremely 
rare. Fractures by muscular action are more frequent in the shaft 
of the humerus than in any other bone. They result from the throwing 
of objects, the use of racquets, in tests of strength and in wrestling. 
Pathologic fractures are not infrequent in the shaft of the humerus, 
and occur from malignant or other disease of the bone, and in nervous 
affections, particularly in tabes dorsalis and syringomyelia. 

Symptoms. — The symptoms of fractures of the shaft are those com- 
mon to all fractures, such as loss of function, pain, tenderness, crepitus, 
abnormal mobility, and deformity. The last is dependent upon the 
site of fracture, the fracturing force, and the pull of muscles. In 
fractures of the upper third the lower end of the upper fragment is 
drawn inward by the pectoralis major, latissimus dorsi, and teres 
major muscles, and the upper end of the lower fragment pulled upward 
by the deltoid, and in some degree by the biceps and triceps muscles 
(Figs. 350 and 351). In fractures of the middle third there may be 
slight overlapping of the fragments ; generally it is absent. In frac- 
tures at the junction of the middle and lower thirds the upper fragment 
is not displaced to any appreciable extent, but the lower fragment is 
apt to be drawn upward and backward by the triceps muscle. 

Diagnosis. — This may readily be made by the usual evidence of frac- 
ture and radiograms. Little difficulty is experienced in making a 
diagnosis. 

Complications. — The complications of fracture of the shaft are 
injury to the blood-vessels or to the nerves, and pyogenic infection in 
open fractures. Injury to the blood-vessels may be the result of the 
fracturing force or may be due to puncture or laceration of the brachial 
artery and its accompanying veins from sharp fragments of bone, and 



314 



TREATISE ON FRACTURES 



is shown by the development of thrombosis and gangrene. Injury to 
the nerves may consist in laceration from sharp fragments, inclusion 
of a nerve in callus, or the result of over-stretching. The nerve most 
frequently injured is the musculospiral, although the median and ulnar 

' nerves may also suffer injury. 
Von Bruns reports 189 injuries 
of nerves complicating frac- 
tures; and of these 138 were of 
the upper extremity. The mus- 
culospiral was involved in JJ 
cases, the ulnar in 19, and the 
median in 17. In 52 per cent, 
of cases of injury to the muscu- 
lospiral nerve the fracture was 
in the middle third, and in 38 
per cent, in the lower third. 
Blenke, in a report of 68 cases 
of musculospiral paralysis found 
that the fracture was in the mid- 
dle third in 56.3 per cent, and in 
the lower third in 41.3 per cent. 
Three forms of musculospiral 
paralysis are recognized : Pri- 
mary paralysis is due to the nerve 
injury caused either by the frac- 
turing force, by the sharp ends 
of fragments, or by being caught 
between fragments and crushed. 
Even with apparent continuity of 
nerve structure the nerve-fibres 
may be destroyed within the neu- 
rilemma. Intermediate paralysis 
(Figs. 352 and 353) is due to the stretching of the nerve over dis- 
located fragments and may appear within a few hours or it may not 
appear for several days. Secondary paralysis does not appear until 
the end of three to four weeks and is due to pressure from surrounding 
or lateral callus or to pressure from cicatricial tissue. The symptoms 
of nerve injury may appear immediately or later, and are shown by 
motor paralysis and loss of sensation over the region supplied by the 
nerve. The most common symptoms of injury to the musculospiral 
nerve is wrist-drop. When the nerve is only irritated hyperesthesia 
is present. 

In the slight forms of paralysis due to compression, it is often the 







FlG. 352. — Rontgenogram of oblique fracture 
of the shaft of the humerus in the region of the 
musculospiral nerve; followed by paralysis of the 
muscles supplied by this nerve. 



FRACTURES OF THE HUMERUS 



315 



rule that recovery takes place within a few months without any treat- 
ment being applied to the nerve itself. In such cases support of the 




Fig. 353. — Drawing to show operation for musculospiral paralysis occurring as a complication of 
fracture of the shaft of the humerus. Small figure shows the nerve (A) pierced by the sharp point of 
the lower fragment and caught between the fragments, as found at operation. Large figure shows 
nerve (A) separated from the fragments of the humerus (the point of lower fragment being removed) 
by a flap of fascia (B), taken from the subcutaneous fascia at the posterior part of the incision (D), 
which has been carried forward and is sutured to the biceps muscle (C). (.See roentgenogram, Fig. 352.) 



forearm and hand, combined with massage, passive motion, and elec- 
tricity, will be followed by restoration to the normal condition. 

When severe injury to the nerve has occurred and the reactions of 
degeneration are present, or in those instances in which secondary 



316 TREATISE ON FRACTURES 

" wrist-drop " has occurred as a result of the presence of callus, oper- 
ative means of restoration of nerve continuity or release from callus 
will be necessary. If the nerve is torn completely across, attempts 
should be made to suture the severed ends by direct apposition or by 
plastic neurorrhaphy: if this is impossible on account of great loss of 
nerve tissue, the intervening gap may be filled by a graft from the 
radial nerve or the ends of the severed nerve may be implanted into 
the median nerve. Perhaps a graft might be furnished by the patient's 
sciatic nerve, which is so large as scarcely to miss the small strip 
required. 

When the paralysis is the result of ensheathing callus, this should 
be chiselled away: this procedure may be expected to give complete 
restoration of function after a sufficient time has elapsed. Y\ "hen the 
paralysis proves to be permanent, the disability may be improved by 
tendon grafting of the muscles in the affected region. 

Treatment. — All fractures of the shaft of the humerus should first 
be carefully examined for evidence of injury to blood-vessels and 
nerves. If these complications do not exist, reduction and immobiliza- 
tion of the fragments should be performed. Fractures of the shaft 
should be thoroughly reduced, under general anaesthesia, if there is 
doubt as to the replacement and no contraindication exists to using 
nitrous oxide or ether. Transverse fractures as a rule remain in good 
position after reduction and proper immobilization. Spiral oblique and 
comminuted fractures are more difficult to retain in proper anatomical 
adjustment by non-operative means. It is probable that the com- 
paratively frequent non-union, delayed union, or pseudarthrosis in 
brachial fractures is due to improper reduction and faulty immobiliza- 
tion. If reduction is not accomplished, muscular tissue is apt to 
separate the fragments and lead to non-union. If a dressing is applied 
which checks motion at the elbow-joint and produces increased motion 
at the seat of fracture, pseudarthrosis is likely to result. In trans- 
verse, and in some spiral, oblique and comminuted fractures, the fol- 
lowing dressing is recommended: surround the arm from elbow to 
shoulder with several layers of sheet-wadding, apply coaptation splints 
anterior, internal, posterior and external, place a small pad in the axilla, 
bind the arm to the chest wall, apply a shoulder cap for protection and 
a small wrist-sling (Figs. 354-356). The weight of the forearm and 
arm will give some traction, but it is by preventing the over-riding of 
the fragments and by securing muscular rest that anatomical apposi- 
tion is preserved and union secured by this dressing. In spiral and 
oblique fractures, when the fragments tend to become displaced, the 
Middledorpf triangular apparatus or the Monks splint may be tried. 



FRACTURES OF THE HUMERUS 



317 




^ 




318 TREATISE ON FRACTURES 

These cases generally require traction, and it may be obtained by the 
Hamilton adhesive plaster extension apparatus supplemented by bed 
traction at night. In those cases in which one is unable to obtain 
anatomical apposition by any of these means open operation and the 
use of a metal plate, nails or screws, or an absorbable fixation appliance 
are advocated. 

Fractures in the upper third of the shaft may often be well treated 
by the simple dressing described for fractures of the upper end of 
the bone. In such cases the axillary pad may act better if wedge 
shaped with the base of the wedge downwards. In this form of dress- 
ing it is well to see that pressure is not great on the brachial artery by 
determining the presence of the radial pulse after the upper arm has 
been bandaged to the chest. 

When the shaft is broken above the insertion of the deltoid the 
upper fragment is liable to be pulled inward by the axillary muscles 
and the lower fragment pulled upward and outward by deltoid action. 
When the fracture is below the deltoid insertion the upper fragment 
may be displaced outward by the pull of that muscle, and the lower 
fragment have its upper extremity displaced toward the axilla by the 
biceps, triceps and coraco-brachial muscles. 

Instead of using coaptation splints for fractures in the middle of 
the shaft a moulded gypsum contour splint on the inner aspect of the 
arm from axilla to the palm of the semi-supinated hand may be 
employed. A short gypsum contour splint from shoulder to elbow 
added on the outside of the arm sometimes may be needed for addi- 
tional support. 

In fractures of the lower part of the shaft angular deformity is not 
uncommon. This is due to the elbow being flexed by the muscles 
attached to the condyles of the humerus. Accordingly these bring the 
upper end of the lower fragment forward, when gravity causes the 
forearm to drop. 

After reduction low shaft fractures are usually satisfactorily main- 
tained in coaptation by means of a plastic contour splint moulded to 
arm, forearm and palm with the elbow flexed at right angle and the 
wrist extended with the hand supine. The plastic splint should be 
reen forced at elbow by additional layers, or an angle of metal. The 
right angle posture of the elbow is not advisable as a rule in fractures 
close to or involving the condylar end of the bone. 

After-results. — In uncomplicated fractures of the shaft of the 
humerus, union occurs in three to five weeks. With comminution of 
fragments union requires a longer time, possibly five to eight weeks. 
Fractures of the upper and of the lower third, uniting with the forma- 
tion of considerable callus or deformity, are often followed by a 



FRACTURES OF THE HUMERUS 319 

moderate degree of impairment of motion at the shoulder- or elbow- 
joint, respectively. 

Failure of union occurs more frequently following fractures of 
the shaft of the humerus than of any other bone. Von Bruns records 
376 cases of ununited fractures among 1274 cases of all bones. Of 
these he estimates that only 56 per cent, of recoveries follow resection. 
In 187 cases of pseudo- arthrosis of the humerus so treated, 98 re- 
covered, 3 were improved, 73 were unimproved and 5 died. 

The causes of delayed union and pseudo-arthrosis may be inter- 
posed muscular tissue, injury of nerves or blood-vessels, or necrosis of 
the ends of the fragments. General systemic conditions may here as 
elsewhere be the cause. 

The treatment consists in massage, injection of blood, or irritating 
substances such as tincture of iodine, the use of Bier's hyperemia ; and 
finally open operation with resection of the fragments or the inlaying 
of an autoplastic bone graft applied laterally, or the insertion of an 
autoplastic bone dowel into the medullary cavity. 

Fractures of the Lower End of the Humerus 
Varieties of Fractures. — The following forms of fracture of the 
lower end of humerus may be described: (1) supracondylar; (2) dia- 
condylar; (3) intercondylar, T, Y, or atypical; (4) separation of the 
lower epiphysis; (5) external epicondyle ; (6) external condyle; (7) 
capitellum; (8) internal epicondyle; (9) internal condyle; (10) 
trochlea. 

In a consideration of fractures of the lower end of the humerus 
there are several very important facts to be borne in mind. The 
normal outlines (Figs. 357-360) as shown by rontgenogram, should be 
carefully studied, in the adult and in children. Certain varieties are 
seen more often in childhood, while other forms are met with more 
frequency in adult life. Fractures occurring during childhood are, 
as a rule, the result of indirect violence transmitted through the hand 
and forearm to the elbow. The majority of these fractures observed 
in children result from hyperextension, combined with abduction or 
adduction. On the other hand, fractures of the lower end of the 
humerus observed in adult life are usually the result of machinery 
accidents or direct crushing injuries, and are seldom observed occur- 
ring from indirect violence as a result of a fall upon the hand with the 
elbow in a position of hyperextension. When fractures do occur in 
adults from indirect force, the resulting fracture partakes of the 
nature of a sprain-fracture, as a rule. On account of this diversity in 
etiology and in lesions observed during childhood and adult life some 
authorities have been led to consider these fractures separately. 

Other differences observed in these two classes are that while, in 



320 



TREATISE ON FRACTURES 



children, marked deformity may be followed by distinct disability for 
a period of from six months to a year, still in the course of several 
years the absorption of callus, bony development, and adaptability of 

Fig. 357- FlG. 358. 




Fig. 359- Fig. 360. 

Figs. 357 and 358. — Rontgenograms of normal adult elbow region. Anteroposterior and lateral views. 



the parts to certain motions give a result that often can hardly be dis- 
tinguished from a perfect one. In adults, however, the reverse is gen- 



FRACTURES OF THE HUMERUS 



321 



■erally the case. Unless good and very often perfect anatomical appo- 
sition of the fragments is obtained, the resulting changes in the carry- 




FlG. 361. — Supracondylar fracture of humerus, very little displacement of fragments. Anteroposterior 

view. (See Fig. 362.) 

Fig. 362. — Supracondylar fracture of humerus, extension type. Lateral view. (See Fig. 361.) 




Fig. 363. — Supracondylar fracture of humerus. Lower fragment has stripped off periosteum for 
a considerable distance from the diaphysis with resulting ossification along periosteum. Anteroposte- 
rior view. (See Fig. 364.) 

Fig. 364. — Supracondylar fracture of humerus. Lateral view. Extension type. (See Fig. 363.) 

ing angle and the development of osteoarthritis will be followed not 
only by deformity but by great impairment in function. 
21 



322 



TREATISE ON FRACTURES 



Supracondylar Fractures (Figs. 361-364). — In this form of frac- 
ture the fracture line occupies a more or less transverse position 
across the humerus just above the tips of the external and internal epi- 
condyles. It should not l^e confused with a low fracture of the shaft 
(Figs. 365 and 366) or with a diacondylar fracture. In 103 fractures 
of the lower end of the humerus Plagemann found 43 supracondylar 
fractures. 'Wendt in 134 fractures, 61 cases, and in a later classifica- 
tion 102 times in 302 fractures of the lower humeral end. Hilgen- 
reiner found in no fractures of the lower end 21 instances of this 
variety. Of the 43 supracondylar fractures of Plagemann' s classifica- 
tion, all were observed in children between the ages of three to fourteen 





years with the exception of 3 cases, occurring at eighteen, thirty-two 
and forty-eight years. 

The supracondylar fractures have been grouped in the following 
four classes by Kocher, and in these classes Plagemann divides his 43 
cases as follows: 31 extension fractures, 5 flexion fractures, 5 ab- 
duction fractures. 2 adduction fractures. 

In the extension fractures the line of fracture is from a point just 
above the attachment of the joint capsule on the anterior surface, up- 
ward and backward, and in addition the line of fracture runs from a 
plane on the external surface inward and upward. The fracture is 
the result generally of a fall upon the outstretched hand with the elbow 
in hyperextension and abduction; the resulting fracture takes place 
just above the attachment of the joint capsule. This fracture is seen 



FRACTURES OF THE HUMERUS 323 

so frequently in children on account of the greater strength of the 
capsule than that of the attached bone. Fractures of this variety are 
never observed in adults produced in this manner, but are always the 
result of direct violence. The dislocation backward of the lower end 
of the humerus may be great but in some cases little dislocation is 
present. 

In flexion fractures the line of fracture is low posteriorly and runs 
forward and upward. This form of fracture is very rare. Its mechan- 
ism is more or less theoretical. It is considered to be the result of a 
fall upon the extensor surface of the semi-flexed forearm, and it is 
thought that the line of force is transmitted directly upward in the line 
of the long axis of the humerus. When it is considered that the 
condyles occupy a plane anterior to this long axis, it can be readily 
understood how the cubital process may be fractured from the lower 
end of the shaft of the humerus and displaced upward. In fractures 
by extension the lower end of the upper fragment is displaced an- 
teriorly by its fellow fragment, while in the flexion variety of fracture 
the lower end of the upper fragment is displaced posteriorly. 

In the abduction fracture the line of fracture runs from inward 
and below upward and outward. These cases appear to> be the result 
of hyperabduction with the elbow in full extension. 

In the adduction fractures the line of break is the reverse, being 
from below and on the outside to a point upward and inward. These 
fractures are the result of hyperadduction with the elbow in full ex- 
tension. The last two varieties may be incomplete and show only an 
infraction of the outer or inner cortex of the bone. 

Symptoms. — The symptoms common to all fractures of the lower 
end of the humerus are pain, tenderness, swelling, ecchymosis, loss of 
function. In addition to these there are symptoms characteristic of 
the different fractures. In the fracture by extension the usual de- 
formity is an anterior displacement of the lower end of the upper 
fragment forward and a posterior displacement of the lower frag- 
ment with the attached structures of the elbow-joint. The condition 
at first glance closely resembles a posterior dislocation of the radius 
and ulna, and the two conditions should carefully be differentiated. 
This posterior displacement is due to the fracturing force, to the 
muscular pull upward and backward of the triceps muscle, and to the 
upward pull of the biceps and brachialis anticus muscles. In addition 
the attachment of the forearm muscles to the lower fragments tend to 
rotate the lower fragment forward, producing a certain degree of 
flexion. As a result of these forces the upper arm just above the elbow 
forms an obtuse angle with its opening posterior. Crepitus is present 
in all cases unless the dislocation of the fragments is great or there is 



324 TREATISE OX FRACTURES 

interposition of soft parts between the fragments. Abnormal mobility 
is always present in complete fractures. 

In flexion fractures, which are rarely observed, the lower end of 
the upper fragment is posterior to the lower fragment. In these frac- 
tures, as well as in the abduction and adduction fractures, the deformity 
is not great. Crepitus and abnormal mobility are always present 
except in the incomplete form. 

Diagnosis. — This can generally be made by the presence of the 
above noted symptoms. In fractures about the elbow-joint, a general 
anaesthetic usually should be given, not only for diagnosis but also for 
reduction. The conditions should be differentiated from posterior 
luxation of the radius and ulna. The normal relative position of the 
epicondyles and the olecranon process will aid in arriving at a correct 
diagnosis. A radiogram in anteroposterior and lateral planes should 
be made before reduction for diagnosis and afterward to determine if 
anatomical reposition of the fragments has been accomplished. 

Diacondylar Fractures (Figs. 367-370). — Under this heading are 
included those transverse partially intra-articular fractures occurring 
above the line of the epiphysis. By some authors, they are classi- 
fied as low supracondylar fractures and by others this variety is 
not differentiated from a supracondylar fracture. These fractures, 
however, have been recognized by Kocher, by Chutro. and by Ash- 
hurst. The line partakes of the character of a supracondylar frac- 
ture by extension. The line of fracture is. however, lower, is more 
or less crescent-shaped and traverses the olecranon and coronoid 
fossa?. The lower fragment consists of the entire articular surface, 
together with the epicondyle, and there is generally a marked slipping 
up of the posterior portion of the periosteum with generally lateral 
and often posterior displacement of the lower fragment. The line of 
break is above the epiphyseal line. 

The mechanism of this fracture is essentially the same as that of a 
supracondylar fracture by extension, although it may be produced by a 
fall directly on the extensor surface of the flexed forearm. A rare 
variety of this fracture is the fracture of the Posadas type (Figs. 371 
and 2>7 2 )' detailed by Posadas and also by Ashhurst. in which the 
fracture produced by flexion causes the lower fragment to be displaced 
forward and to be complicated by a posterior dislocation of the radius 
and ulna. 

Symptoms. — To the general symptom- of fracture about the elbow- 
there may be added crepitus, localized pain on pressure, occasionally 
abnormal mobility and deformity. The crepitus can be obtained by 
flexion and extension of the elbow. Abnormal mobility is dependent 
upon the degree and extent of attachment of the joint capsule to the 



FRACTURES OF THE HUMERUS 325 

Pig. 367. Fig. 368. 





Fig. 367. — Diacondylar fracture of humerus with marked lateral and posterior displacement of lower 

fragment. 

Fig. 368. — Diacondylar fracture of humerus with little displacement of fragments. 





fracture of humerus, with line of fracture running downward and 

outward (adduction type), 
fracture of humerus with line of fracture running downward and 

inward (abduction type). 

upper fragment. In some cases the abnormal mobility will be limited 
to hyperabduction and adduction. Deformity is not always present; 
when considerable displacement is present the lower fragment may be 



326 



TREATISE ON FRACTURES 



displaced laterally to either side and posteriorly. Anterior dislocation 
of the lower fragment is rare. An absolute diagnosis of this form of 
fracture is practically impossible without the radiogram. Here par- 
ticularly an anteroposterior and lateral view should be taken before 
reduction. 

Diagnosis. — This is made mainly by the radiogram. The condition 
should be differentiated from supracondylar fracture and separation 
of the entire lower epiphysis. From the latter it may be distinguished 
by the detachment of the entire lower portion of the diaphysis from 
the lower fragment, and one should be on guard to recognize this im- 
portant point. In separation of the lower epiphysis small fragments 
of the diaphysis frequently remain attached to the epiphyseal cartilage. 




■ fracture of humerus, "Posadas' type," 
Fracture by flexion. 
372- — Diacondylar fracture of humerus, 



with dislocation of head of radius. 



Intercondylar, T, Y, or Atypical Fractures (Figs. Z7i~Z7S)- — 
These fractures are generally the result of direct violence, are fre- 
quently compound and are usually observed in adults. Of the eleven, 
cases reported in Plagemann's statistics all cases were observed in 
adults with the exception of one seen in a twelve-year-old boy. The 
essential features arc the separation of the condyles from the shaft and 
their separation from each other. The lines of fracture are rarely 
typical, there is often great displacement of fragments and marked 
injury of the overlying soft parts. Perforation of the soft parts and 
skin may be produced by the sharp ends of fragments. The upper 
line of fracture may be more or less transverse and about the line of a 
supracondylar fracture. Running from this line there is generally a 



FRACTURES OF THE HUMERUS 



327 



vertical line of fracture separating the two condyles irregularly. The 
separation of the condyles from each other may vary from a mere 
fissure to great displacement. At times marked comminution of frag- 
ments may he present. 

The fracture most frequently is the result of direct violence such as 
machinery accidents. Madelung considers that it may, however, be 
produced by the direct wedge-like action of the ulna in falls upon the 
flexed forearm. 

Symptoms. — As most of these fractures are the result of direct 
violence, the local signs of marked contusion of the soft parts are 
present. Swelling, ecchymosis, the formation of blebs, and superficial 



Fig. 374- 



Fie. 37 






Fig. 373. — Intercondylar T or Y fracture of lower end of humerus. 
Fig. 374. — Intercondylar T or Y fracture of lower end of humerus. 
Fig. 375. — Intercondylar atypical fracture of lower end of humerus. 

areas of gangrene are frequent. If the fracture is compound, we have 
in addition the evidences of such an injury. In typical fractures there 
is independent mobility of the condyles, broadening of the width be- 
tween the condylar limits, mobility of the condyles upon the shaft of 
the humerus, and often marked deformity so that the position of the 
condyles may be anterior or posterior to the end of the shaft. The 
latter may at times be palpated between the separated condyles, while, 
on the other hand, the ulna may apparently be displaced between them. 
Crepitus is present in nearly all cases and is only limited by the degree 
of displacement of the fragments, the interposition of soft parts, or 
the presence of marked oedema. 

Diagnosis. — Cases of suspected intercondylar, T, Y, or atypical 
fractures should have lateral and anteroposterior radiograms made. 



328 TREATISE ON FRACTURES 

In many obscure cases a positive diagnosis can be made only by this 
procedure. 

Separations of the Lower Epiphysis i Figs. 376-379). The lower 
epiphysis of the humerus is developed from four centres of ossification. 
A study of the radiogram of the lower end of the humerus shows 
that before the appearance of any of the centres the lower end of 
die diaphysis extends below the level of the olecranon and coronoid 
fossa?, that it is rounded, and it is impossible to determine the internal 
from the external condyle without a study of the relative positions 
of the bones of the forearm. The centres of ossification appear in 
the following order : capitellum. from one to two years : internal epi- 
condyle ( epitrochlea ) . fifth to sixth year; trochlea, eleventh year: 
and external epicondyle. twelfth year. The centres of ossification 
increase in size so that those of the capitellum. trochlea, and epi- 
condyle are entirely fused from the twelfth to the thirteenth year, and 
are entirely united with the diaphysis at the fifteenth year. The centre 
of the internal epicondyle does not fuse with the diaphysis until the 
eighteenth year. 

Separation of the lower epiphysis is observed during childhood up 
to about the fourteenth to the eighteenth years. Y\ "hen occurring near 
the eighteenth year the lesion is usually a separation of the epiphysis 
of the internal epicondyle. The line of separation may be entirely 
through the epiphyseal cartilage, or there may be attached to the 
epiphyseal cartilage portions of the lower end of the diaphysis. The 
line of separation is variable and the portion of attached diaphysis is. 
as a rule, fairly constant when present. Separations that are produced 
by a fall upon the hand with the elbow in a position of full extension 
may have a portion of the posterior edge of the diaphysis attached. In 
addition there is usually marked stripping up of the periosteum. In 
separations produced by direct violence the portion of attached dia- 
physis will depend in a great measure upon the direction of the frac- 
turing force. The fracture line may at times involve a portion of the 
epiphyseal line and then run upward through either condyle. 

Symptoms. — In addition to the usual signs of fracture, swelling, 
tenderness, and ecchymosis, there is present crepitus, which is usually 
character. Deformity when present consists of slight or mod- 
erate displacement pi >sterk>rly or laterally of the lower epiphysis. This 
may be recognized by the fact that the radius and ulna may he dis- 
placed or laterally at will by the surgeon and with little 
force. Abnormal mobility may be developed by the same manipula- 
Many cases of epiphyseal separation resemble sprains of the 
elbow and formerly were often 50 diagnosed. There is, however, per- 
sistent inability to move the forearm on account of localized pain and 



FRACTURES OF THE HUMERUS 329 

Fig. 376. Fig. 377- 




Figs. 378 and 37g. — Separation of lower epiphyses of humerus, with small fragment of diaphysis 
attached. Anteroposterior and lateral views. 



330 



TREATISE ON FRACTURES 



tenderness, and these two symptoms persist much longer than would 
be expected in a sprain about the elbow -joint. 

Diagnosis. — This can usually be made by the presence of persistent 
tenderness, pain on motion, soft crepitus, ability to produce an exag- 
gerated degree of abduction and adduction at the elbow-joint, and by 
careful interpretation of the radiographic findings. 

In a study of epiphyseal separations by the radiogram it is very 
important to bear in mind the time of appearance of these centres of 
ossification, and the date of their fusion with each other and with the 




j8i. — Fractures of external epicondyle of humer 



diaphysis. In many instances a diagnosis by the radiogram of epi- 
physeal separation can be made only by a comparison of the injured 
with the uninjured side before attempts at reduction have been made. 
In the early years of life diagnosis will depend entirely upon the altered 
relation of the centres of ossification to the diaphysis. Later, during 
childhood or before fusion of the epiphyses with the diaphyses, it 
may be possible to distinguish epiphyseal separation here as elsewhere 
by the fact that it is only in the very early years of life that a pure epi- 
physeal separation occurs. After the sixth or seventh year, and in some 
instances earlier, it is noteworthy from a radiographic point of view 



FRACTURES OF THE HUMERUS 



331 



that in epiphyseal separations a small portion of the diaphysis is very 
often separated from the diaphysis, and remains attached to and is 
displaced with the epiphysis. When callus has formed, it may be pos- 
sible to make a diagnosis of epiphyseal separation by radiograms from 
the presence and amount of callus formed after injuries in which, at 
the time of accident, a positive diagnosis was impossible. 

Fractures of the External Epicondyle (Figs. 380 and 381). — 
Fractures of the external epicondyle are infrequently seen. The 
fracture may be the result of direct violence acting upon the external 
surface of the lower end of the humerus; or of indirect violence, as 





S. 3S2 AND 383.- 



external condyle of hu 



id lateral views 



when a tear-fracture results from hyperadduction of the elbow. It 
may be associated with posterior dislocation of the radius and ulna. 

Symptoms. — The symptoms of this fracture are localized pain, 
swelling and tenderness, slight crepitus over the external condyle, and 
the possibility of moderate hyperadduction of the forearm by forcible 
motion. 

Fractures of the External Condyle (Figs. 382-385). — Fractures 
of the external condyle were observed by Plagemann in 15 instances 
out of 103 fractures of the lower end of the humerus. This frac- 



332 



TREATISE ON FRACTURES 



ture is frequently observed in children. The line of fracture may 
run upward and outward obliquely from the joint surface, so that the 
detached fragment may consist of a part of the trochlea, the capitellum, 
and the epicondyle. In many instances the line of fracture begins 
near the external trochlear ridge, and runs obliquely outward to a 
point below the epicondyle. This form is especially seen in children, 
and at times great difficulty may be observed in deciding between a 
fracture of the condyle and an epiphyseal separation in which a con- 
siderable portion of the diaphysis is attached to the dislocated epi- 
physis. The fracture may be produced by a fall directly upon the 





Figs. 384. and 385. — Fracture of externa! condyle of humerus, fall upon hand with arm hype 
extended. Anteroposterior and lateral views. 



external condyle: by a fall upon the hyperflexed elbow, the external 
condyle being the point of impact : by hyperadduction of the elbow, in 
which instance the fracture partakes of the nature of a tear-fracture: 
or by a fall upon the hand, with the elbow in full extension, the force 
being transmitted through the radius to the capitellum. 

Symptoms. — Examination shows localized pain, tenderness, swell- 
ing, and in some instances contusion of the soft parts over the external 
condyle. In addition there will be found crepitus, mobility of the 
condyle if the detached fragment is large, possibility of hyperadduc- 
tion, and occasional displacement of the fragment upward. When the 
last condition is present, hyperabduction of the forearm is possible 
and a condition of cubitus valgus may be obtained. When marked 



FRACTURES OF THE HUMERUS 



333 



displacement of the fragment is present the roughened edge of the 
large fragment may be felt. Widening of the joint may be present. 
Dislocation backward of the ulna may be present as a complication. 

Fractures of the Capitellum (Figs. 386 and 387). — This fracture 
is one of the rarest of fractures occurring at the lower end of the 
humerus. Kocher described four cases under the classification of 
" fractura rotuli humeri." Cases have been reported by Stimson, Flint, 
Lorenz, Jopson and Hahn. The injury consists in the separation of the 
articular surface of the capitellum and is entirely intra-articular. All 
of the reported cases appear to have been produced Dy transmitted 





Figs. 386 and 387. — Separation of the epiphysis of the capitellum of the humerus, to which is attached 
a small portion of the diaphysis. Anteroposterior and lateral views. 



force acting through the head of the radius, while the elbow was in a 
position of flexion, or by muscular action in which the head of the 
radius exerted upward pressure against the capitellum by the pull of 
the biceps muscle. Several reported cases were the result of crushing 
injuries or direct violence. 

Symptoms. — The symptoms consist in pain, tenderness, swelling, 
and limitation of motion. This limitation is dependent in a great 
degree upon the displacement of the fragment. The elbow is generally 
held in a position of partial extension and passive motion may be com- 
plete. The condition resembles in certain ways a fracture of the head 
of the radius. Supination is limited and possible only with consider- 



334 



TREATISE ON FRACTURES 



able pain. Palpation may determine the presence of the fragment near 
the head of the radius. 

Fractures of the Internal Epicondyle ( Figs. 388-39] 1. — In many 
instances detachment of the internal epicondyle is a separation o£ 
the epiphysis, which only fuses with the diaphysis of the humerus at 
about the eighteenth year. This lesion is seen most often between the 
ages of ten and eighteen years, and consists in complete detachment of 
the ephysis either alone or in conjunction with posterior luxation 
of the ulna and radius. The fracture or separation may l>e the result 
of direct violence, such as a fall upon the abducted arm ; m^re fre- 





1 displaced 



temal ept; 
forward. 



Anteroposterior and lateral views. 



quently. however, it results from hyperabductiun of the elbow while in 
a position of full extension, forming a "sprain"- or tear-fracture. 
Attached to the epic mdyle are the superficial flexor muscle- and the 
internal lateral ligament. It is readily seen, therefore, how hyperab- 
ductii • may produce this separation. It is frequently 

found in conjunction with posterior dislocation of the radius and 
ulna, a lesion produced most frequently during hvperextension and 
hyperabduetion of the elbow. The attached epicondyle is generallv 
displaced forward and downward, and the ulnar nerve may at the 
same time suffer injury. 



FRACTURES OF THE HUMERUS 



335 



Symptoms. — When the fragment is small and not displaced, the 
symptoms consist in localized pain, a tenderness, and crepitus. When 
the fragment is displaced downward and forward there is swelling, 
pain on using the superficial flexor muscles of the forearm, ecchymosis, 
and crepitus during reduction of the displaced fragment. Motion at 
the elbow is not interfered with, as a rule, except for limitation due 
to pain. 

Injury to the ulnar nerve, either immediately as a result of the 
fracturing force, or secondarily from involvement in callus, is a com- 
plication to be feared, yet is very infrequent. 

Diagnosis. — This can be readily made by the evidences of localized 
injury, crepitus, and the presence of the dislocated fragment at a point 





-Fracture of the internal epicondyle of humerus. Marked downward and forward displace- 
ment of the epicondyle. 
-Fracture of the internal epicondyle of the humerus without displacement of the fragment. 

below and in front of its normal position. Rotation of the fragment 
is at times present. Wilms states that in all his cases of posterior 
dislocation of the forearm occurring from the tenth to the fifteenth 
years of life there was present a separation of the internal epicondyle. 
Fractures of the Internal Condyle (Figs. 392-394). — This frac- 
ture of the lower end of the humerus is unusually rare. This is 
shown by the statistics of Mouchet, 1 case in 170 fractures; Chutro, 
2 cases in 106 fractures; Kocher, 6 cases in 45 fractures; and Ash- 
hurst, 4 cases in 56 fractures of the lower end of the humerus. The 
line of fracture as a rule runs from the inner border above the internal 
epicondyle downward and outward to the trochlear surface, and at 
times bevond the external border of the latter. The fracture in the 



336 TREATISE ON FRACTURES 

majority of cases is the result of a fall upon the extensor surface of 
the ulna with the elbow in a position of flexion, the force being trans- 
mitted through the ulna to the trochlea with a resulting breaking off of 
the internal condyle. Fractures by abduction or adduction may be 
produced in childhood, when the resulting lesion is more of an epi- 
physeal separation with an attached portion of the diaphysis in the 
region of the trochlea. The displacement of the condyle is usually up- 
ward, inward and backward; at times little if any displacement will be 
present. In the case illustrated, due to a fall upon the ulnar surface of 
the forearm with the elbow in a flexed position, the displacement was 
lateral, and the upper end of the condylar fragment was tipped forward 
on extension of the forearm. At times when the displacement is 




Fir,. 392. — Tear-fracture of the internal condyle of the humerus. 
Fig. 393. — Tear-fracture of the internal condyle of the humerus. 
Fig. 394. — Fracture of the internal condyle of the humerus. 



posterior the ulna and radius may be displaced with the internal 
condyle. 

Symptoms. — The symptoms observed in fracture of the internal 
condyle are swelling, greatest about the internal aspect of the elbow, 
localized pain and tenderness, ecchymosis, abnormal mobility of the 
internal condyle revealed by palpation, broadening of the distance be- 
tween the epicondyles, change in the relation between the epicondyles 
and the tip of the olecranon, crepitus, loss of the carrying angle, and 
marked deformity, if the radius and ulna are displaced posteriorly 
with the displaced internal condyle. 

Diagnosis. — This can usually be made by the local signs of frac- 
ture, the broadening of the lower end of the humerus with mobility of 
the internal condyle, the possibility of excessive abduction and adduc- 
tion with the elbow fully extended, and a study of the radiogram. 
When there is in addition a dislocation of the head of the radius, its 
head may be felt below and posterior to the external condyle. 

Fractures of the Trochlea ( Figs.. 395-397). — This is a rare frac- 



FRACTURES OF THE HUMERUS 



337 





Figs. 39s, 396, and 397. — Fracture of the capitellum. (International Clinics. Dr. John H. Jopson.) 
22 



338 TREATISE OX FRACTURES 

ture at the lower end of the humerus. By many authorities it is not 
even mentioned. Langier first described the fracture; Stimson reports 
two cases. The fracture consists in a chipping off of a part of the 
trochlear surface. From the few cases reported it is difficult to 
describe the mechanism of the fracture; it seems to occur from falls 
upon the hand with the elbow in a position of hyperextension, the 
force being transmitted through the radius, the interosseous ligament, 
and the ulna. Falls directly upon the upper extensor surface of the 
ulna with the elbow in a position of partial flexion may transmit suffi- 
cient force to break off a portion of the trochlea. 

Symptoms. — The symptoms of a fracture of the trochlea are those 
of an indefinite injury to the elbow-joint. In addition to localized 
pain, tenderness, and effusion into the joint, it may be possible to 
palpate the displaced fragment. In a case reported by Stimson the 
fragment could be palpated beneath the epitrochlea. Both cases re- 
ported by Stimson were followed by good results and did not require 
removal of the displaced fragments. 

When the elbow has been crushed under heavy pressure or shat- 
tered by a gunshot injury, the lines of breaking are too irregular to 
classify. 

Complication's of Fractures of the Lower End of the Humerus 

The important complications of fractures at the lower end of the 
humerus are : open wounds. Volkmann's ischaemic contracture, injury 
to important blood-vessels, and injury to the musculospiral. median, or 
ulnar nerves. 

Open fractures at the lower end of the humerus are sometimes 
seen, and usually are caused by direct violence. This is especially the 
case in the supracondylar fractures of the adult, and at times in the 
epiphyseal separations observed during childhood. 

Volkmann's Ischaemic Contracture. — This complication is observed 
not only in fractures about the elbow-joint but also in fracture of the 
bones of the forearm. The condition, first described by Yolkmann in 
1880. consists in a primary disturbance of the blood supply of the 
muscles from a dressing that is too tight or from other causes that 
produce pressure upon the muscles, and as a result marked ischsemia 
occurs. This compression is shortly followed by a true rigor mortis 
of the affected muscles, and later by hyaline degeneration and the re- 
placement of the muscle-fibres by fibrous connective-tissue. Xot only 
does this change effect the muscles, but the nerves appear to be simi- 
larly destroyed, though to a less degree. The sheath of the nerves is 
particularly involved. The degeneration, muscular and neural, may be 
complete or partial, and may involve some or all of the muscles and 
nerves. The flexor muscles seem to be most often involved. The 



FRACTURES OF THE HUMERUS 339 

lesion is not always due to the application of tight splints, dressings, 
or bandages. Cases have been observed in which no constricting 
dressing was used. In many cases, however, a dressing is applied 
which at the time is sufficiently loose not to impede the circulation, but 
which causes constriction later when increased swelling has taken place, 
either from hemorrhage or oedema. In many of the cases the duration 
of the constriction has not been long. How rapidly the development 
of this grave ischsemia occurs is not definitely known, but certainly not 
longer than from six to twelve hours may suffice. The condition is 
seen particularly in children, and has been seen following thrombosis 
of the veins, compression of the main blood supply to the affected 
limb, and exposure to prolonged cold. Following the degeneration of 
the muscular fibres contractures rapidly develop. 

Symptoms. — In patients who develop Volkmann's ischsemic con- 
tracture, it has been discovered that, while as a rule the dressing has 
not been applied so tightly as to be primarily uncomfortable, complaint 
of severe pain in the affected part is sometimes made in the first 
twenty-four hours. This may be looked upon by the patient's family 
and also by his physician as being the usual pain expected in fractures, 
and the dressing therefore may not be removed or even examined. 
Thus the only period at which successful measures can be adopted to 
prevent the development of ischemic contracture passes without relief 
being given. In some cases the pain is not sufficiently severe to attract 
the attention of the family or nurses. When the patient is seen after 
the lapse of twenty-four hours, there may be found, on removing the 
splint or other dressing, that there is an area of superficial necrosis 
where the point of greatest pressure occurred. The hand will already, 
or at most within the following forty-eight hours, have assumed the 
characteristic attitude described by Volkmann. This superficial area 
of necrosis may subsequently slough and involve deeper structures than 
the skin. Examination of the extremity will reveal a board-like hard- 
ness of the muscles and absence of voluntary contraction with painful 
and restricted passive motion. The fingers first show signs of con- 
tracture, the hand is in the position of pronation, the elbow semi-flexed, 
the wrist extended, the metacarpophalangeal joint extended, and the 
interphalangeal joints flexed. Flexion of the wrist permits of ex- 
tension of the fingers. The flexor group of muscles is permanently 
shortened, and show marked wasting. The fingers are generally cold 
and blue, and at the end of twenty-four to forty-eight hours vesica- 
tion may be noticed, particularly of the fingers. In severe cases there 
may be ischsemic neuritis of the median and ulnar nerves, with reaction 
of degeneration, and loss of sensation in certain regions. Glossy skin, 
changes in the finger-nails and trophic ulcers develop from slight me- 
chanical injuries. The final stage is a claw-like deformity of the hands. 



340 TREATISE ON FRACTURES 

Treatment. — This ischemic contracture may, in many cases, be 
improved by the conscientious application of massage, passive motion, 
and electricity. The result, however, in a great measure will depend 
upon the original muscular and nerve destruction. In severe cases 
little permanent benefit will be obtained by non-operative means. 

Various operative measures have been suggested and used to im- 
prove the condition. They consist of : lengthening of the flexor 
tendons of the forearm; freeing by dissection of the median and ulnar 
nerves from the surrounding cicatrix, and their transplantation to the 
subcutaneous tissue ; myotomy and tenotomy of muscles and tendons ; 
and resection of the radius and ulna with the removal of a portion of 
each sufficient to allow full extension of the fingers. In cases not 
operated upon, considerable improvement may be obtained by the 
use of suitable splints and apparatus, which correct to a degree the 
deformity. 

Volkmann's ischsemic paralysis should be differentiated from the 
contractures of anterior poliomyelitis, Little's disease, and peripheral 
nerve paralysis. 

Injury to important blood-vessels is rarely observed in fractures 
of the lower end of the humerus, except in patients in whom consider- 
able injury has been done to the soft parts in fractures due to direct 
violence. When severe injuries occur to the soft parts, the fracture 
may be an open one, and thrombosis, laceration of important blood- 
vessels, and large hematomas may result. 

Injury to Nerves. — Injury to the musculospiral, median or ulnar 
nerves complicates some fractures of the lower end of the humerus. 
Primary, intermediary, or secondary nerve lesions may result. Pri- 
mary nerve lesions consist in laceration or compression of the nerve. 
Intermediary lesions, causing motor or sensory paralysis, may arise 
from injury following attempts at reduction or late manipulations of 
the fragments. Secondarv nerve paralysis is due to the pressure of 
developed callus. 

Many of the nerve lesions complicating these fractures are not 
permanent and rarely require operation. Their frequency is shown by 
the statistics of Ashhurst, i case (median) in 56 cases; Coenen, 3 
cases (musculospiral) in 31 supracondylar fractures; Destot, Vignard 
and Barlatier, 1 case (musculospiral) and 1 case (median) in J2 frac- 
tures above the elbow ; Broca and Mouchet, 9 cases of nerve injury 
among 78 elbow fractures. Miiller considers that nerve complications 
develop in one-fifth of all cases of supracondylar fractures (Ashhurst). 

Treatment. — The anatomical reconstruction of the lower end of the 
arm bone in all these injuries requires that the fragments be returned to 
their normal relations. The functional reconstruction requires that the 
position of the bones be not allowed to interfere with the mechanical 



FRACTURES OF THE HUMERUS 341 

perfection of the elbow-joint, that the muscles have opportunity to act 
successfully, that damage to nerves and blood-vessels be repaired, in a 
manner to correct wrist-drop from musculospiral palsy, pressure 
anaemia, and similar complications, and that the contour of the limb 
lose not its original symmetry and beauty. 

The full accomplishment of these ends is possible only when ac- 
curate diagnosis is united with mechanical precision and surgical judg- 
ment. It must be admitted at the outset that in some instances it will 
be impossible for the patient to obtain these essentials to perfection. 
Even operation, replacement and direct fixation may prove incapable 
of giving a good result. 

The complicated mechanism of the elbow and its association with 
man's manual dexterity make its reconstruction after fractures an 
important surgical problem. 

Fortunately the majority may be treated with practical success, 
if the practitioner in charge will take the trouble to carefully examine 
and compare both arms of the patient, under general anaesthesia, and 
use as a check the dry bones taken from a human skeleton. The 
character of the fracture, the nature of the displacement, and the 
way to correct the deformity will then usually be apparent to a medical 
graduate of average knowledge and ability. 

Elbow fractures are so notoriously liable to lead to suits for mal- 
practice that a considerable number of physicians hesitate to undertake 
their treatment. Anaesthesia for the primary examination, and fre- 
quent inspection of the limb entirely uncovered by fracture dressings, 
will probably reveal any condition which renders the protection of 
consultation with a surgical specialist desirable. 

It is true that checks to the hinge-like action of the joint or a 
diminished pronation and supination of the hand, from unreduced frag- 
ments, osteophytes, intra-articular adhesions, or extra-articular con- 
tractures and rigidity demand first consideration. Nevertheless, it is 
important to conserve the so-called carrying angle ; its cosmetic, as well 
as its functional, value is important. 

The reconstruction of the elbow-joint is not, as a rule, a difficult 
problem, if the exact line or lines of fracture and the form of displace- 
ment are known, and if the doctor is alive to the mechanics of the 
undertaking. The various accessories of diagnosis and treatment, 
utilized in other fractures, generally permit the patient, unless the 
circumstances are exceptional, to secure a useful and undeformed 
joint. It is not just, however, to expect the average medical prac- 
titioner to obtain in the more complicated cases such uniformly satis- 
factory and perfect cures as the surgical specialist of metropolitan 
centres. The latter has a wide experience, which may be readily sup- 



342 



TREATISE OX FRACTURES 



plemented by the expert radiographer and the aseptic plant of a modern 
hospital operating room. 

Secondary ankylosis of the joint is a common result of bad frac- 
tures and a likely occurrence in badly treated ones. This impaired 
mobility of the joint surfaces is to be averted by accurate replacement 
of the fragments, followed by careful massage and passive motion 
begun early. Prompt correction of the bony distortion is essential. 

In the treatment of the various fractures of the lower end of the 
humerus, several facts should be borne in mind. Before reduction it 
is wise to have anteroposterior and lateral view radiograms made. 
After reduction and whatever method of fixation has been used it is 

4 judicious to have the part 
radiographed again. Success 
in the treatment of these 
difficult fractures depends 
largely upon complete reduc- 
tion and the retention of the 
obtained anatomical coapta- 
tion of fragments under the 
guidance of radiograms. It 
is by accurate apposition of 
the fragments and fixation for 
the requisite time that exuber- 
ant callus, fibrous infiltration 
of the parts, and arthritic 
deposits of new bone are 
avoided. To insure the reduc- 
tion of fractures of the lower 
end of the humerus, a general 
anaesthetic should usually be 
employed as an adjunct. Some 
of these fractures are impacted and may require a considerable amount 
of force to break up the impaction and to permit proper reduction of 
the fragment. Reduction ma}- be accomplished only after hyperex- 
tension, longitudinal traction with countertraction, flexion, hyperflex- 
ion, lateral moulding and manipulation. 

Usually reduction is far more readily accomplished than is the 
retention of the fragments in their normal position. ' The method of 
retention which usually gives the best results, because it makes use of 
the triceps muscle, Nature's elbow splint, is the modified Jones posi- 
tion, that is, hyperflexion and supination. The best results are obtained 
by this position in the following fractures of the lower end of the 
humerus: supracondylar fractures (with the possible exception of the 
Kocher flexion type) ; diacondylar fractures; separation of the lower 




Fig. 398. — Diacondylar fracture of the humerus. Xote 
the marked posterior displacement and moderate rotation 
of the lower fragment. (See Fig. 399.) 



FRACTURES OF THE HUMERUS 343 

epiphyses ; fractures of the external epicondyle, external condyle, in- 
ternal epicondyle, and internal condyle. Hyperflexion of the elbow, 
as is shown so admirably by Ashhurst, gives the greatest stability to 
the broken lower humeral end. Flexion of the lower fragment on the 
forearm is prevented on account of the relaxation of the forearm 
muscles attached to internal and external epicondyles, and the point of 
insertion of the triceps muscle, being carried anterior to the long axis 




The central figure (made after Rbntgenogram, Fig. 398) shows the effect of the pull of the triceps mus- 
cle in maintaining deformity. The figure to the right shows this very clearly. The figure to the left 
shows the splinting action of the triceps muscle in maintaining apposition of fragments when hyper- 
flexion is used after proper reduction. (Small figures modified after Ashhurst.) 

of the humerus, tends to hold the lower fragment in its proper relation 
with the upper one; thus posterior displacement of the lower fragment 
is impossible (Figs. 398 and 399). Robert Jones says that if we desire 
to improve statistics of good functional results, we must recognize 
the hyperflexed and supinated position as the chief ally in the treat- 
ment of severe injuries to the elbow. The extended position of the 
elbow maintained by an anterior contour gypsum splint, securing the 



344 



TREATISE ON FRACTURES 



normal carrying angle of the elbow is often entirely satisfactory. The 
elbow should not be quite in full extension. 

In the treatment of the Kocher flexion type of supracondylar frac- 
ture, continued hyperflexion and supination will be followed usually by 
good anatomical retention of the fragments, provided proper reduction 
is first obtained. If, however, the surgeon depends upon continuous 
hyperflexion without first having absolutely reduced the fragments, it 
is often impossible to prevent recurrence of deformity. In a very 
small percentage of cases in which, because of marked obliquity of the 




Fig. 400.— Method of reduction of fractures of the lower end of the humerus. Longitudinal traction 
and counter-traction, supination, flexion, and hyperflexion. 

line of fracture it is impossible to engage the fragments, a better 
result may possibly be obtained by a right-angle anterior angular splint. 
This is a dangerous posture for treating fractures of the lower end of 
the humerus, because of the risk of producing cubitus varus. It is prob- 
ably preferable in such case? to obtain anatomical apposition by open 
operation and direct fixation with screws or some similar device, when 
reduction is not easily maintained by the almost fully extended posture 
or hyperflexion. 

In the intercondylar, T, Y, and atypical fractures, it is very difficult 



FRACTURES OF THE HUMERUS 



345 



to properly reduce or mould the fragments into their normal relations 
and to maintain proper anatomical apposition. In these cases it is wise 
sometimes to adopt open operation and the direct fixation of the 
fragments. 

In fractures of the internal epicondyle it is generally possible to 
maintain the fragment in its proper position by hyperflexion. If, how- 
ever, this cannot be done the almost extended position or open fixation 
is advisable. In some instances subcutaneous nailing may answer. In 
troublesome fractures of the trochlea and capitellum, open operation 
and the removal of the detached fragment is recommended. 

In the reduction of these fractures at the lower end of the humerus 



Fig. 402. 




Figs. 401 and 402. — Old fracture of external condyle of humerus, untreated. (See Figs. 403 and 404.) 

an assistant should grasp the arm firmly, steady it, and at the proper 
time make counter-traction ; the surgeon should first hyperextend the 
elbow-joint, separate impacted fragments, and then, by means of 
manipulation, engage the ends of the fragments ; when this procedure 
has been accomplished, direct traction should be made upon the con- 
dyles ; internal rotation should be corrected and the elbow slowly flexed, 
hyperflexed, and the forearm supinated (Fig. 400). If proper re- 
duction is accomplished, cubitus valgus (Figs. 401-404) or varus 
(Figs. 405-408) will be rare in the types of fracture in which this form 
of dressing is advised. The degree of hyperflexion will depend upon 
the amount of swelling present. In cases with much swelling it is 
always wise to abstain from using flexion for a few days. As a rule it 



346 



TREATISE ON FRACTURES 



should stop at the point which causes discomfort of which is likely to 
cause compression of the hrachial artery. It is dangerous in the early 
days of a severe fracture in out-patient hospital practice because the 
great swelling may endanger circulation and be unrelieved. The radial 
pulse should always be felt, after the bandage or other dressing has 
been applied, and an unobstructed beat of the radial artery proved to 
be present. 

There are several suitable dressings for maintaining this flexed 
position. One is an adhesive plaster strap so applied as to give an 
even pull upon the surfaces of the forearm and arm. This strap 
should be two inches in width. It is applied by placing its centre 




external condyle of humerus, untreated 
) 

over the upper outer surface of the arm, and the two ends are then 
carried around the extensor surface of the supinated forearm at a point 
about two inches above the radial styloid. A wrist-sling made of a 
cotton roller bandage surrounded by rubber-tubing may be used to sup- 
port the limb (Figs. 409 and 410). A good form of dressing is that 
made by the cotton roller bandage properly applied. 

In young children liable to disarrange the dressing, a tightly fitting 
undershirt with sleeve long enough to come beyond the fingertips of the 
injured limb may be satisfactorily utilized. The shirt is put on with 
tin- broken arm through its appropriate sleeve, the elbow acutely flexed, 
and the end of the sleeve closed with needle and thread. Then the 



FRACTURES OF THE HUMERUS 



347 



loose end of the sewn sleeve is sewed firmly to the neck of the shirt in 
front of the child's opposite sternoclavicular joint. 

If the adhesive strap method is used its ends, as Cotton has wisely 
said, should cross at an angle and be pinned as well as stuck together. 

The hyperflexion and supination or extension with supination 
should be maintained for at least three weeks. The dressing should 
be inspected every other day during the first week and twice weekly 
during the succeeding two weeks ; it should be changed whenever neces- 
sary. At the end of three weeks the acuteness of the hyperflexed posi- 




Figs. 403 and 406. — -Old fracture of internal condyle of humerus. (See Figs. 407 and 




tion or the extended elbow position, whichever has been chosen, should 
be decreased slowly so that at the end of the fourth week the elbow is 
brought to a right angle and the limb is bandaged and carried in a 
sling. Passive motion should be begun carefully and should at no time 
be sufficiently violent to cause undue pain. Careful massage of the 
soft parts may be indulged in from the end of the first week. It may 
even be started immediately after injury by an experienced surgeon. 
Early passive motion, if injudiciously employed, and forcible manipu- 
lation are liable to dislocate fragments, increase the formation of 
excessive callus, and delay the resumption of normal motion. 



348 



TREATISE ON FRACTURES 



The near-extended posture of the elbow-joint, the acutely flexed 
position, and occasionally right-angle flexion may be used in most of 
these lesions ; provided that the medical attendant knows the line of 
fracture, reduces the fragments, keeps them reduced, inspects the arm 
frequently, and prevents the moderate displacement which may result in 
a secondary cubitus varus or valgus. 

The fracture dressing should be simple but efficient. Fixation in 
the extended position of the elbow with the hand supinated has been 
advocated. This posture is valuable in maintaining the divergent angle 
between the axes of the arm and forearm and permitting easy recog- 




Fics. 407 and 408. — Right cubitus varus. Old fracture of internal condyle of humerus. (See Figs. 
405 and 40O.) 

nition of any tendency to abnormal adduction or abduction. Thus the 
production of cubitus varus or valgus is rendered unlikely. The joint 
should be almost but not quite fully extended. The extended elbow in 
condylar fractures may be maintained by a deviating anterior wooden 
splint properly padded or by anterior and posterior moulded splints of 
gypsum or other plastic material. The position is not especially incon- 
venient or irksome to the patients. It should not be full extension. This 
is irksome and there is a risk of over-extension displacing fragments. 
The gypsum encasement may be used, if it is split so as not to make 
injurious circular constriction in case of unexpected swelling. 

In some cases the difficulty of diagnosis, the gravity of the lesion 



FRACTURES OF THE HUMERUS 



349 



of the bones and soft parts, the unusual displacement of the fragments, 
the development secondarily of new bony processes and atrophic modi- 
fication of osseous surfaces may cause partial or complete ankylosis of 
the joint and deformity of the limb. It is always wise, therefore, to 
give a guarded prognosis, until the ultimate outcome is clearly 
established. A very little callus in the olecranum fossa will greatly 
limit extension. 

After-results. — In cases of fracture of the lower end of the hume- 



Fig. 409. 



Fig. 410. 








\ 



'L^l 



FlG. 409. — Method of maintaining hyperflexion of elbow by adhesive plaster strip. 
Fig. 410. — Rubber tubing sling. Finished dressing in position of hyperflexion. 

rus the after-results will depend almost entirely upon the perfection of 
reduction accomplished and the proper anatomical retention of frag- 
ments. If these two objects are thoroughly met, the after- results 
should be satisfactory. In adults the after-results are not quite so 
good, as a rule, as in childhood. This is probably due to the greater 
violence necessary in the production of fractures in adults, with its 
consequent greater detachment of periosteum, and severer comminu- 
tion of fragments. In childhood nature has a way of so readjusting 
the parts that in after years perfect functional results may be obtained 



350 



TREATISE ON FRACTURES 



in injuries which at the time of convalescence appeared peless 
that regard. 

The end results in fractures of the lower end of the 
various authors are given by Ashhurst as follows : 



Coenen 

Cotton Ji 

- : ' ' _ - r " ' 
and Bariatiei 









I smite 






z 




1 

-r 


3 
> 

u 


i 

-H 


-_ a 

n 

1 : - 

>3-3 


c 


-" 


: ■- 

- 25 


I - - 

4 - 


:: • 


ami. 

: : 

: j - 




39 
•4 


II (28^) 

1 :: j 


28 (71.8) 


4 (28.5) 


- 


: 



Cubitus Valgus: Cubitus Varus. — These two terms designate the 
changes which may result after fracture at the lower end of the 
humerus. Cubitus valgus denotes an increase in the carrying angle. 
and cubitus varus a decrease, a loss of, or a reverse at, the carrying 
angle normally present The last condition is commonly termed a 
" gunstock " deformity. The carrying angle is the normal angle 
formed by the prolongation at the elbow of lines through the axes ( i f 
the humerus and of the forearm, when the latter is in a position of 
full extension and supination. It normally disappears when the : re- 
arm is pronated or when the forearm is flexed on the arm. It is due 
to the normal obliquity in the transverse plane of the articular surface 
of the lower end of the humerus and in a slight obliquity of the trans- 
verse plane of the upper articular surfaces of the bones of the forearm. 
In a series of ;o cases examined by Ashhurst. the carrying angle varied 
from 162 to 178 degrees. It is greater in women than in men on 
account of the greater width of the female pelvis. Either condition 
may result after supracondylar fractures of the lower end of the 
humerus, although cubitus varus is the more frequent. It has been con- 
sidered by some authorities to occur frequently after fracture of the 
internal condyle, external condyle, or epiphyseal separations. This 
deformity is frequent after fractures of the lower end of the mm 
when the surgeon has treated the injury in the semi-flexed position of 
a right-angle anterior splint or a right-angle trough splint. The- 
to displace the fragments, and especially is this the case in fractures of 
the internal condyle. If the fracture is thoroughly reduced and the 
arm treated by the hyperflexed position or the almost completely ex- 
tende the normal earning angle is much more likely to be 



FRACTURES OF THE HUMERUS 351 

preserved. Perfect reduction must, however, be assured at the time 
the fracture is put up in a retentive dressing. 

The operative treatment of either condition consists in an oste- 
otomy of the humerus in the supracondylar region. For cubitus valgus 
the osteotomy should be performed from the inner surface, and for 
cubitus varus from the outer surface of the humerus. The line of 
osteotomy should be complete, so that the entire thickness of the bone 
is severed. The correction is then made, the wound closed, and the 
arm dressed in full extension and supination on a splint or in a gypsum 
case, being careful to maintain the correct carrying angle. In mild 
cases, however, it is scarcely necessary to correct either of these de- 
formities. Unless the conditions are moderately great, they interfere 
but little with function. 

Cubitus varus or " gunstock " deformity is the commoner of the 
two, and interferes greatly with carrying a bucket or bag, because the 
burden tends to strike the thigh when the patient walks. He must 
compensate for the brachial deformity by greatly bending his trunk 
towards the side of the distorted arm if the weight be heavy. 

The " gunstock " deformity of the arm, termed cubitus varus, is due 
to angular deviation or upward with inward displacement, or both, of 
the whole lower end of the bone or of its internal condyloid portion. 
It may be a primary or a secondary distortion. This can be avoided if 
the medical man is not forgetful of its possibility, and constantly com- 
pares the injured with the uninjured arm in the extended position with 
the hand fully supinated. The normal carrying angle is greater in 
men than in women, and in adults than in children. It also varies in 
individuals of the same age and sex, and is not shown when the hand 
is pronated. Its loss by deformity from fracture is a cosmetic blemish, 
and, if marked, interferes much with the utility of the joint. It is prob- 
ably caused by the fracture dressing or the sling, in which the arm is 
carried, lifting the ulna upward toward the shoulder or permitting the 
ulna, acting as a lever, to displace in the direction of adduction the 
fragment detached from the shaft of the humerus. It may perhaps 
occur from gravity when an imperfectly dressed fractured arm is laid 
across the chest of a recumbent patient. 

Cubitus varus is found in supracondylar fractures, fractures near 
the epiphyseal line, T and Y and comminuted fractures, and fractures 
of the internal condyle. The opposite distortion, cubitus valgus, takes 
place when abnormal abduction of the forearm at the elbow is pro- 
duced by angular or rotary displacement outward of the entire condylar 
extremity or the fractured external condyle. 

The medical man should remember that there is normally no lateral 
movement of the elbow- joint, and that the hinge is primarily con- 



352 TREATISE ON FRACTURES 

structed by the articulation of the ulna with the humerus. The wrist- 
joint, on the other hand, is primarily an articulation of the radius with 
the carpus. 

Secondary cubitus varus and cubitus valgus may perhaps be due 
to an imperfect growth at the epiphyseal line after fractures in that 
region among children. The surgeon is not responsible for its exist- 
ence. It is then not a deformity due to a primary rotation or an early 
deviation occurring during treatment of the fracture. 

Summary of Treatment of Fractures of Humerus 

Upper End. — Restraint of motion, using chest as thoracic splint, 
perhaps compress in axilla, elbow flexed and perhaps carried a little 
forward, wrist sling. Sometimes shoulder cap, preferably of plastic 
materials. Occasionally traction in abduction. Rarely operative 
fixation with nail or screw or suturing of periosteum with catgut. 

Shaft. — At upper part, similar to fractures of upper end of bone; 
in middle, narrow coaptation splints of wood or metal but using also 
thorax as splint, and sometimes adding shoulder cap. Extension 
weight sometimes hung from elbow. Occasionally gypsum contour 
splint on outer aspect or inner side of arm. Lower part of shaft and 
the true supracondylar fracture, right angle splint of wood or metal 
or of plastic material with elbow flexed at right angle and hand supi- 
nated. Elbow should not be supported by a sling lest it cause over- 
lapping. Operation occasionally, to fix with plate or screws or absorb- 
able tube of catgut or fascia, and sometimes after deformed or non- 
union. 

Lower End. — Usually by acute flexion of elbow, maintained by 
adhesive plaster band, hand covered with mitt or sleeve stitched to 
opposite sternoclavicular region, by bandage. Sometimes near- 
extended elbow maintained by anterior deviating wood or metal splint 
or plastic material to sustain carrying angle. Avoid right-angle an- 
terior splint or posterior trough right angle splint, as a rule, though such 
may be used for a few days, while swelling is great. Operation re- 
quired occasionally when reduction impossible or deformed union pres- 
ent. In all fractures of humerus be sure of reduction before applying 
dressing. 



CHAPTER XVI 

FRACTURES OF THE RADIUS AND ULNA 

Anatomy. — The radius (Fig. 411), the outer bone in the forearm, 
plays little part at the elbow but its principal part at the wrist. The 
principal parts of the radius are the disk-like head; the neck, a con- 
striction below the head ; the tuberosity below the head for the inser- 
tion of the biceps tendon; the shaft which, like the ulna, is three- 
sided like a prism, on cross-section, and enlarges as the lower extremity 
is reached; the flattened lower end presents two surfaces, the volar 
and the dorsal, and has the styloid process below at its outer corner. 
The head of the radius presents a cup-like depression at its top to 
articulate with the capitellum of the humerus ; at its lower end it articu- 
lates with the scaphoid and semilunar of the carpus and laterally with 
the head of the ulna. 

The ulna (Fig. 412), the inner bone of the forearm, is parallel to 
and a little longer than the radius. The upper extremity has on its 
anterior aspect the greater sigmoid notch, which articulates with the 
trochlea of the humerus. The olecranon is the hook-like upper ex- 
tremity of the ulna. The triceps muscle is inserted upon the olecranon 
dorsally; the upper portion of this process curves forward over the 
greater sigmoid cavity, and on extension fits into the olecranon fossa 
at the back of the lower end of the humerus. The anterior and upper 
part of the humeral shaft terminates in the coronoid process, which 
fits into the coronoid fossa of the humerus on flexion of the elbow. 
The shaft of the ulna becomes smaller in circumference towards its 
lower extremity and terminates in its head or capitellum, from which 
extends a pointed process called the styloid process. The lower end 
of the ulna articulates laterally with the side of the base of the radius. 

The trochlea of the humerus articulates with the greater sigmoid 
notch of the ulna, the humero-ulnar articulation; the capitellum of 
the humerus with the upper articular surface of the head of the radius, 
the humero-radial articulation, and the radial notch of the ulna with 
the articular circumference of the head of the radius, the proximal 
radio-ulnar articulation. Surrounding these three articulations there is 
a common capsular ligament. In addition there is a radial or internal 
lateral ligament and an ulnar or internal lateral ligament, and the annu- 
lar or orbicular ligament which surrounds the neck of the head of the 
radius for three-quarters of its circumference, the remaining portion 
being formed by the radial articulation of the ulna. 

The carrying angle normally averages for boys, 168 degrees; for 
girls, 178.24 degrees (Ashhurst). This is the result of the fact that 

353 



354 



TREATISE ON FRACTURES 



the axis of the trochlea is not at right angles to the axis of the shaft of 
the humerus, but forms an oblique angle, so that when the forearm is 
extended the axes of the humerus and forearm bones form an obtuse 
angle at the elbow. 

The distal radio-ulnar joint is formed by the articular surface of 
the ulnar notch of the radius and the circumference of the capitellum 
of the ulna, and also bv the triangular cartilaginous disk between the 



Fig. 412. 



Anterior border 



Groove for 
externa'. 

Groove " 
externa! brevis pol 




Neck 

Bursal surface 
Tuberosity 



"-~v" 



.'. M- : '■---. ■ ': :ri;r 



Tip of olecranon ■ 
jreatet 

sigmcii _l--.v- 
Coronoid process 



Az:tr.:r': rie: 



Nutrient canal . 
I-:;r: sseoos bolder. 



Sigmoid cav - 

Semilunar I 
Scaphoid ; - 



Articular facet 
- - - 



head of the ulna and the cuneiform bone. In addition there are fibres 
known as the anterior and posterior radio-ulnar ligai 

Pronation and supination are produced by rotati : upper 

end of the radius on a longitudinal axis through its head and neck : 
and at its lower end by the rotation of the radius around the head oi 
the ulna. The entire movement may be likened to rotation around a 
cone with its apex through the head of the radius and its circumfer- 
ence at its lower extremity. The range of motion is about 180 degrees 
around the base of the 



FRACTURES OF THE RADIUS AND ULNA 355 

Surface Markings. — The radius is palpable throughout its en- 
tire extent, except for a. small portion of its upper third. The head of 
the radius can be readily palpated, and this fact is of importance in 
determining fracture of the radius. By placing the thumb over the 
head of the radius, which may be felt just below the external condyle 
of the humerus, its mobility may be determined by pronation and 
supination of the forearm. In thin persons the tuberosity of the radius 
may also be felt. Of special importance in examination of the fore- 
arm are the normal radial arch in the lower one-third of its palmar 
surface and the relation of the radial styloid in comparison with the 
ulnar styloid. Normally it will be found to be about a quarter of an 
inch below the ulnar styloid. 

The ulna can be felt throughout along its posterior border. Es- 
pecial attention should be given to the position of the olecranon in 
relation to the internal and external condyles of the humerus. In 




Fig. 413. — Lower portion of left humerus with radius and ulna. Incomplete double fracture of 
the radius and ulna. The radius sustained an incomplete fracture both at the middle and at 4 cm. from 
the wrist-joint. The ulna sustained incomplete fracture at the lower third, at 7 cm. and at 4 cm. from 
the end. From a boy fourteen years of age whose arm was torn off by machinery. (Mutter Museum, 
No. 1307.) 

thin persons the coronoid process may be felt anteriorly on semi- 
flexion of the elbow-joint.' 

Statistics. — The frequency of fractures of the bones of the forearm 
has been variously estimated by different authors. Bruns, from a 
study of 8560 fractures, reports 752 (8.7 per cent.) fractures of 
radius and ulna; 215 (2.5 per cent.) fractures of ulna; 103 (1.2 per 
cent.) fractures of the olecranon, and 828 (9.6 per cent.) fractures of 
the radius. Chudowsky, from a review of 2366 fractures, estimates 
125 (5.32 per cent.) fractures of the ulna and radius, 79 (3.34 per 
cent.) fractures of the ulna, and 253 (10.69 P er cent.) fractures of the 
radius. Immelmann collected 4048 fractures, and of these 84 (7.5 
per cent.) involved the ulna and radius, 23 (2.03 per cent.) the ulna, 
and 123 (11.1 per cent.) the radius. Plagemanus statistics from 
Midler's clinic at Rostock reports 1393 fractures, all with radiographic 
diagnoses, and of these 134 (9.62 per cent.) cases involved the ulna 
and radius, 20 (14.3 per cent.) cases the ulna alone, 11 (0.79 per 



356 



TREATISE ON FRACTURES 



cent.) the olecranon and coronoid processes, and j$ (5.24 per cent.) 
the radius alone. 

Fractures (Combined) of Ulna and Radius 
Statistics. — Of the 134 cases of fracture of both bones of the fore- 



FlG.415. 









Figs. 414 and 



-Fracture of shafts of radius and ulna. 
Anteroposterior and lateral view 



Marked over-riding of fragments 



arm recorded in Plagemann's classification, the following division was 
made: fractures of the upper end of both bones of the forearm, 7 
(0.509 per cent.) ; fractures of the shafts of the bones, 47 (3.37 per 
cent.) ; fractures of the lower end of both bones, 80 (5.74 per cent.). 
Etiology. — The cause may be direct or indirect violence. When 



FRACTURES OF THE RADIUS AND ULNA 



357 



direct violence has been operative, the cause is generally a blow, a kick, 
or a fall upon the forearm at the site of fracture. When indirect 
violence has been received, the cause is usually a fall upon the hand. 
In cases due to direct violence the seat of fracture is at or near the 






same level in both bones. When due to indirect violence the level of 
fracture in the two bones varies. Generally the site of fracture is at a 
higher place in the ulna than in the radius. A few rare cases of frac- 
ture by muscular action have been recorded in which there was a con- 
tributing form of external violence, as in shovelling or in rising upon 
the hands while on the ground. The fracture is rarely observed in 



358 



TREATISE OX FRACTURES 



children. Oberst, in a study of 92 cases of fracture of both bones, 
found the fracture at the same level in 50. In 3 1 the fracture of the 
radius was higher, and in 1 1 the fracture of the ulna was higher. In 
4 instances the fracture involved the upper third, in 36 cases the middle 
third, and in 52 cases the lower third and the junction of the lower 
and middle thirds. 

The line of fracture may be transverse, oblique, or spiral, and 
rarely longitudinal. The fracture may be partial, incomplete, sub- 
periosteal, or " green-stick *' ( Figs. 413-419). A fairly common form 
of fracture observed at the lower third of the radius is the " cortex 




Fig. 418. — Fracture of shafts of radius and ulna. Over-riding of fragments. 
Fig. 419.— Complete fracture of shafts of radius and incomplete fracture of ulna, 
out reduction of fragments, with posterior deformity. 



fracture " seen in children. In childhood the cortex is flexible, and as 
a result of impaction and slight flexion the cortex bulges outward. In 
adults the same form of violence will produce a transverse fracture. 

The fracture may be open, comminuted, or multiple. Extensive 
damage to the soft parts is the result of severe direct violence, and 
marked displacement of the ends of the fragments may be the result. 

Displacements. — The displacements noticed in fractures of both 
bones of the forearm depend in a great degree upon the fracturing 
force, the position of the fracture, its character, the pull exerted by 
attached muscles, and the weight of the forearm. In fracture of the 
upper third of both bones there is in many instances not only fracture, 



FRACTURES OF THE RADIUS AND ULNA 



359 



but also a dislocation of one or more bones or an associated fracture 
of the lower end of the humerus. 

In fracture the result of severe direct violence, the displacement 
of the fragments may be considerable. The usual displacements are 
angular, rotary, over-riding. In many fractures of both bones, little 
if any displacement is noticed, with the exception of slight angulation 
due to the fracturing force, or to the weight of the forearm. Of special 
importance are : supination displacement of the upper fragment of 
the radius in forearm fractures between the attachment of the biceps 
and the insertion of the pronator radii teres; inward or central dis- 
placement bringing the ends of the fragments of the radius and ulna 




Fig. 420. — Drawing to show the usual displacement of fragments in fractures of the shafts of the 
radius and ulna. Note over-riding and pulling over of lower fragment of radius by the action of the 
pronator quadratus muscle. 

together in fractures about the middle third (Fig. 420) ; displace- 
ments due to the pull of the pronator radii teres, causing pronation of 
the upper fragments of the lower middle region of the forearm ; and 
that caused by spasm of the quadrate pronator in fractures at the 
junction of the middle and lower thirds or below that point, which 
results in pronation of the hand with the rest of the lower arm 
supinated or held in mid-supination. 

Symptoms. — The symptoms of simultaneous fracture of the radius 
and ulna will depend to a great degree upon the character of the injury. 
In incomplete, subperiosteal, "green-stick" and cortex fractures, de- 
formity may be absent or slight. The usual symptoms then will be local- 



360 TREATISE ON FRACTURES 

ized pain, tenderness on pressure, disinclination to use the part, and 
swelling. When deformity is present, it is of the angular variety. One 
bone may be the seat of a complete fracture, in which case crepitus 
may be obtained, while the other bone may be incompletely fractured. 
Fractures of the above character are observed up to almost the fifteenth 
year. Sometimes the fracture is not recognized at the time of injury, 
and the local symptoms may be ascribed to a severe contusion and the 
true condition understood only at the end of several weeks, when the 
presence of moderate callus formation will attract the attention of the 
child's parents. 

In incomplete fracture of both bones, in addition to the local signs 
of fracture observed in the incomplete forms of fracture, there are dis- 
placement of the fragments, deformity, crepitus, and often marked 
swelling of the forearm and bruising of the soft parts. 

Complications. — The complications of fracture of both bones of 
the forearm that may arise are gangrene, Volkmann's ischaemic con- 




FlG. 421. — Bone of right upper extremity, union with co-ossification. The fracture occurred above 
the middle of the forearm. The uniting callus is smooth but exuberant, and firmly binds the radius 
and ulna together. The forearm is fixed midway between pronation and supination. It is difficult to 
state in the radius the precise location of the fracture. (Mutter Museum, No. 1307.02.) 

tracture, diffuse cellulitis, union with angular displacement, union with 
fusion of the fragments by a bridge of callus (Fig. 421), delayed 
union, non-union, pseudo-arthrosis, and persistence of failure of full 
supination, due to rotary displacement of the upper or lower fragments 
of the radius, according to the situation and direction of the line of 
fracture. 

Diagnosis. — In incomplete fractures the diagnosis may usually be 
made by the persistence of localizing symptoms at the point of sus- 
pected fracture. In complete fractures the diagnosis as a rule is 
obvious. Radial and ulnar injuries resembling fractures, especially 
fracture of the incomplete variety, should be carefully radiographed. 
In some few cases a positive diagnosis is otherwise impossible. 

Treatment. — In incomplete fractures in which there is no deform- 
ity, the indications for treatment are simple. In such fractures of the 
Upper two-thirds of both bones, the arm and forearm should be im- 



FRACTURES OF THE RADIUS AND ULNA 361 

mobilized on an anterior angular splint for a period of about three 
weeks. 

In incomplete fractures, in which there is angular deformity, the 
fracture should be made even complete, if this rupture of fibres is 
necessary to obtain correction of the deformity. Here, as elsewhere, 
sometimes careful bending may reconstruct the bent bone without 
causing complete fracture with displacement. This is the ideal reduc- 
tion. In a few cases reduction may be accomplished by traction on 
the hand, counter-traction above the elbow with the latter semi-flexed, 
and local moulding and pressure at the seat of fracture. In fractures 
of this form involving the upper two-thirds of the forearm, immobili- 
zation after reduction is best accomplished by the application of an 
anterior angular splint applied to the arm and forearm, with the elbow 
in a position of semi-flexion and the hand in full supination (Fig. 422). 
Full supination is advised, because a wide separation of the radius and 
ulna is obtained in this position, and when the pull of the biceps muscle 
tends to supinate the upper fragment of the radius the lower fragment 
is brought into its correct position by this procedure. If, after the 
application of the anterior angular splint, there is noticed any tendency 
toward posterior bowing at the seat of fracture this may be corrected 
by the application of an additional posterior splint applied from the 
olecranon to the wrist (Figs. 473 and 474). A better plan is the appli- 
cation of moulded gypsum splints or an encasement to maintain the 
desired position. 

In complete fractures, reduction of the fragments will often call 
for not only considerable force, but also considerable manipulation of 
the fragments. The arm should be flexed at the elbow, an assistant 
should make steady counter-traction above the elbow, and the operator 
traction above the wrist. By means of considerable force and manipu- 
lation reduction in many cases may be accomplished. A general 
anaesthetic is advisable whenever reduction may be painful or difficult. 
After reduction has been obtained the parts should be immobilized as 
above described. In fracture of the lower third or at the junction of 
the middle and lower third of both bones, immobilization of the elbow- 
joint is not always necessary. As a rule the fragments may be held 
properly reduced by the use of an anterior splint, extending from the 
fold of the elbow to the metacarpophalangeal joints of the fingers, and a 
posterior splint, applied from the same level above to the midmeta- 
carpal region below. In the application of splints in fractures of 
the bones of the forearm, a preliminary bandage next to the skin should 
not be applied. Such bandaging is seldom if ever necessary under- 
neath a splint dressing anywhere. A longitudinal pad to maintain 
separation of the radial from ulnar fragments should not be used ; it 
is of little value in preventing bridges of callus, and may cause very 



362 



TREATISE OX FRACTURES 




• 









I 



I 

7 



FRACTURES OF THE RADIUS AND ULNA 



363 



harmful pressure. Proper reduction and fixation are the means of 
obviating such complications. Gypsum contour splints are especially 
valuable because they fit accurately. A slight depression in the surface 
may be made with the surgeon's thumb at any spot where a little addi- 
tional pressure is needed to keep a fragment in position. This is done 
just before the splint hardens. Attention should be paid to preventing 
the recurrence of angular deformity, and the dressing should be care- 
fully watched so as to avoid undue constriction or pressure necrosis 
(Figs. 425 and 426). The development of non-union, pseudo-arthro- 
sis or faulty union should be carefully observed and appropriate means 
for their correction instituted. 

In fractures of radial shaft below the insertion of the round pro- 
nator, the upper fragment may be pronated strongly. The surgeon 




Fig. 425. — Photograph showing areas of pressure necrosis from poorly padded anterior and poste- 
rior splints applied too tightly. 
Fig. 426. — Posterior deformity from green-stick fracture of shafts of radius and ulna before reduc- 



should see that the lower part of the bone is not allowed to unite in a 
supine position. 

In cases of fracture of both bones, in which the fragments cannot 
be properly reduced or in which reduction cannot be anatomically 
maintained, open operation with direct fixation is advised. The de- 
velopment of pseudo-arthrosis or non-union is usually due to faulty 
immobilization or to the interposition of soft parts. In many cases of 
delayed union longer immobilization with general treatment will effect 
a cure. In pseudo-arthroses open operation is often necessary, with 
the resection of the ends of the fragments and the insertion of an 
autogenous bone-graft, or the fixation of the freshened bone ends by 
plates, wires, nails or screws. 

Results. — Union occurs in the majority of cases in from three and 
a half to six weeks. The subsequent usefulness of the part depends in 
great measure upon the character of the fracture, its position, and the 



364 



TREATISE ON FRACTURES 



amount of callus necessary to obtain union. When excessive callus 
occurs, pronation and supination may be greatly interfered with and 
fusion of the two bones by callus may occur. In cases in which pro- 
nation and supination are impaired, without the presence of excessive 
callus to account for the condition, the disability may be due to the 
fact, as pointed out by Konig, that union occurs with the lower frag- 
ment pronated and the upper fragment supinated, rotary malposition 
being the result. Supination is therefore impaired to the limit in 
which it is possible for the upper fragment to supinate. When union 
takes place with the fragments displaced towards each other and the 

Fig. 427. Fig. 428. 




Fig. 427. — Tear-fracture of the tip of the olecranon process bv muscular action. 
Fig. 428. — Fracture of olecranon exostosis from direct pull upon flexed elbow. 

hand pronated, the interosseous membrane is stretched at the point of 

union of fragments by moderate rotation so that supination is limited. 

Isolated Fractures of the Ulna. 

Statistics.— Plagemann's statistics include 31 cases of fractures of 
the ulna. Of these there were 11 cases (0.78 per cent.) of fracture 
of the olecranon and eoronoid process. Of these the olecranon alone 
was involved in 7 eases ; there were 1 5 cases ( 1.07 per cent.) of fracture 
of the shaft, and 5 eases ( 0.359 P er cent.) of fracture of the lower 
end or head of the ulna. 

Fractures of the Olecranon.— Fractures of the olecranon process 



FRACTURES OF THE RADIUS AND ULNA 



365 



(Figs. 427-432) may be the result of direct violence, of muscular 
action, or of a combination of both. Those resulting from direct 
violence, such as a fall upon the olecranon or the extensor surface of 
the upper forearm, are usually transverse in direction ; they may, more- 
over, be comminuted or compound. Fractures the result of muscular 
action are always transverse and single. Olecranon fractures may be 
associated with fractures of the coronoid process. That fractures of 
the olecranon are not so frequently the result of direct violence alone 

Fig. 429. Fig. 430. 




Fig. 429. — Incomplete fracture of base of olecranon process. Direct violence. 
Fig. 430. — Comminuted fracture of olecranon. Direct violence. 

is shown by the frequent absence of local trauma. Many of these 
fractures unquestionably are the result of the sudden flexing of the 
elbow by the muscles — the triceps holds the olecranon firmly and, as the 
patient falls upon the hand or semi-flexed forearm, an extreme force 
is indirectly brought to bear on the ulna at the point of articulation 
of the olecranon with the trochlea of the humerus, and fracture results. 
Most fractures resulting from direct violence are comminuted in 
character. 

Displacement. — In a consideration of the displacement that may 
occur in fracture of the olecranon it should be remembered that the 
three articulations of the elbow-joint are surrounded by an articular 



366 TREATISE ON FRACTURES 

capsule. This is attached to the ulna just in front of the tip of the 
olecranon and extends forward on the lateral aspect of the olecranon 
to a point anterior to the coronoid process. It forms with the annular 
ligament a firm support to the component bones of the joint. Further 
support is given by the attachment of the triceps muscle, which is 
chiefly inserted into, and completely surrounds, the olecranon process ; 
it also gives lateral expansion to the ulna and antebrachial fascia. It 
is for this reason that fractures of the olecranon, transverse in char- 
acter and at a position well back towards the tip. are often observed 




Fig. 431. — Transverse fracture of olecranon process. Muscular action. Very little separation of 

fragments. 

Fig. 432. — Transverse fracture of olecranon process. Marked separation of fragments. 



without any displacement. The fragment is mostly intra-articular 
and is held attached to the remaining portion of the ulna by the articu- 
lar capsule and by the lateral expansions of the insertion of the triceps 
muscle. When, however, the fracture line is situated more anteriorly, 
separation occurs, as it also may when the fracture is the result of 
muscular action. In such instances the lateral expansion of the inser- 
tion of the triceps muscle and the articular capsule are torn ; and there- 
fore displacement readily occurs by the action of the triceps muscle 
(Fig. 433). This displacement is always greater on flexion at the 
elbow and usually may be made to disappear on full extension. 



FRACTURES OF THE RADIUS AND ULNA 367 

Symptoms. — The usual signs of fracture, swelling, ecchymosis, 
effusion of blood into the elbow-joint, local pain, deformity (Figs. 434 
and 435), and tenderness are present. The arm may be carried in any 
position. There is generally actual loss of power of extension. Ex- 
tending power, however, may be present to a limited degree when the 
periosteum and the lateral expansion of the triceps tendon are not 
completely torn. Extension is best tested by having the patient attempt 
it against resistance. Crepitus can generally be obtained, even in those 
cases in which there is considerable separation of the fragments, by 
manipulation of the fragments during full extension at the elbow. 
Separation of the fragments may be detected by palpation. A radio- 




gram will always make the diagnosis certain. A source of error pos- 
sible in radiographic diagnosis is the belief that a partially ossified 
process or a normal epiphyseal line in a young subject is a fracture line. 
The olecranon may have one or two centres of ossification. These 
centres increase in size until about the sixteenth to the seventeenth 
year, when complete ossification of the epiphyseal line takes place. 
Separation of the olecranon epiphysis is rare, and can only be diag- 
nosed by radiographic examination and careful comparison with its 
fellow of the opposite arm. If, in the presence of clinical localizing 
signs of injury to the epiphysis, the radiograms show distinctly a 
marked displacement as compared with the other side, one is justified 



368 



TREATISE ON FRACTURES 



in making a positive diagnosis. The surgeon should make himself 
familiar with the radiographic appearances of the bones at the elbow- 
joint at various ages. The ossific centres are often mistaken for 
fracture fragments. 

Treatment. — Reduction of this fracture is readily, as a rule, ac- 
complished by full extension of the forearm with some form of trac- 
tion above the olecranon. Union in man}- cases is fibrous and not 
bony. This is due to a certain amount of separation of fragments 
and the interposition of small portions of fascia. Open operation 
should be followed by firm bony union. Xon-operative treatment con- 
sists in nearly full extension at the elbow, and the application of a well- 

Fic. 434- Fig. 435. 




plete fracture at base of 



padded splint to the flexor surface of the arm, forearm and hand, 
extending from the axilla to the palm of the hand. This splint should 
be held firmly to the arm with circular strips of adhesive plaster and 
a bandage; an additional strip should be placed above the olecranon 
and run downward in a diagonal direction, to hold the olecranon 
firmly apposed to the remaining ulnar fragment (Figs. 436 and 437). 
If no separation of fragment is present, immobilization may be made 
upon a well-padded internal right angular splint. The internal splint 
should hold the elbow-joint at a right angle (Fig. 438). Look out 
that a pressure sore is not produced over the epicondyle. 

In young adults, members of the working class and others, whose 
occupation depends in a great measure upon the ability to fully extend 



FRACTURES OF THE RADIUS AND ULNA 369 




/ 



hIHIR 



Fig. 437. 



Fig. 438 







Figs. 436 and 437.— Straight splint applied to internal surface of arm and flexor surface of fore- 
arm tor fractures of the olecranon process. Note application of adhesive straps. One strap particu- 
larly should be placed just above the process. 

Fig. 438.— Application of the internal right-angle splint for fracture of the olecranon process when 
there is no separation of fragments. 



24 



370 



TREATISE OX FRACTURES 



the arm, and also in all instances where great separation of fragments 
is present, operation and suture of the fragments are recommended. 
Convalescence is more rapid, union is bony and a strong useful arm is 
obtained. A U-shaped incision, approximation of the fragments and 
suture with twenty-day chromic catgut or kangaroo tendon, closure of 
the wound, and the application of a splint holding the arm in a little 
less than full extension will meet all operative indications (Fig. 439). 








Fig. 439. — Method of suture in fractures of the olecranon process attended by separation of frag- 
ments. 1 v.o lateral sutures of kangaroo tendon approximate the fragments and interrupted sutures 
of chromic catgut hold together the torn periosteum. The skin and subcutaneous tissue wound is closed 
by interrupted sutures of linen thread and the arm immobilized on a splint in a position of full 



Subcutaneous nailing or subcutaneous suturing through transverse 
drill tunnels in the two fragments may be employed for coapting the 
fragments. 

With the non-operative treatment, the splint should lie discarded at 
the end of four weeks, and active and passive motion given. Mas-age 
should be instituted at the end of the first week, or even earlier. In 
operative cases the splint may be omitted earlier. 

Results. — Fractures of the olecranon treated by non-operative 
means are followed by good functional results in the majority of cases. 



FRACTURES OF THE RADIUS AND ULNA 



371 



Fibrous union is more frequent than is generally supposed, and while 
the function of the part may be decreased somewhat, it is good for all 
practical purposes, except in those instances in laborers where the 
degree of extension is of paramount importance. Bony union results 
generally in those cases in which there is no separation of fragments 
and in the operative cases. In some instances it is remarkable that, 
although there is a marked appreciable gap between the fragments and 
only fibrous union, extension with considerable power is present. 
The olecranon is similar to the patella in its function, and demands a 
very similar treatment when it is fractured. It is probable that suture 





Fig. 440. — Fracture of coronoid process of ulna. 

Fig. 441. — Fracture of the coronoid process of the ulna, complicating a posterior dislocation of 

radius and ulna previously reduced. 

of the capsule may be as efficient as sutures carried through the frag- 
ments. In this it resembles to a certain extent fracture of the patella, 
though in the latter injury there is more opportunity for separation 
because of the greater tendency to wide laceration of the muscular 
tendinous envelope. 

Fractures of the Coronoid Process (Figs. 440-444). — This 
fracture was considered extremely rare. The radiograph has, how- 
ever, revealed the more relative frequency with which it occurs. 
Although many authorities consider isolated fracture of the coronoid 
process extremely rare, except as an accompaniment. of backward or 
lateral dislocation of both bones of the forearm, the three cases here 



372 



TREATISE ON FRACTURES 



illustrated, in which there was no dislocation or tendency to disloca- 
tion present, were seen by Dr. Kelly. Its occurrence is probably not 
very unusual. 

The mechanism of this fracture is not definitely understood. Some 
surgeons consider it the result of a fall upon the ulnar border of the 
hand with the forearm in a position of partial flexion, the force being 
transmitted through the ulna to the coronoid process, which is broken 
by counter-pressure against the trochlea of the humerus. By other 
writers it is believed to be due to action of the brachialis anticus muscle, 
and to partake of the nature of a tear- or sprain-fracture; other 
authorities attribute its occurrence to hyperflexion of the elbow-joint. 
It is suggested by the authors that coronoid fracture may result from a 

Fig. 442. Fig. 443. Fig. 444. 




Fig. 442. — Fracture of coronoid process of ulna. 
. 443. — Fracture of coronoid process of ulna complicating a fracture of the olecranon process. 
444. — Fracture of base of coronoid process of ulna complicating a diacondylar fracture of the 
humerus. 



Fig. ,,, 
Fig. 444. — Fracture 



fall upon the hand, with the forearm in a position of partial flexion, 
transmitting the vulnerating force through the interosseous ligament 
from the radius to the ulna and thus driving the coronoid process 
against the trochlea. The force thus transmitted may or may not be 
severe enough to produce an accompanying dislocation backward of 
both radius and ulna at the elbow. An accompanying feature of the 
anterior portion of the head of the radius has been described by some 
authors. 

The line of fracture may be at the tip or at the base of the process. 
When due to muscular action we would think that only a portion of 
the process would be torn off, while, when produced by indirect force 
applied through the forearm, the fracture line is at the base of the 
process. 



FRACTURES OF THE RADIUS AND ULNA 



373 



Displacements. — In fractures of the process unaccompanied by 
posterior dislocation of both bones of the forearm, displacement of 
the process is slight. This is due to the firm attachment of annular and 
lateral ligaments and the tendon of the anterior brachial muscle. 
When there is present a posterior dislocation of both bones of the 
forearm, the fragment tends to remain in normal relation with the an- 
terior surface of the trochlea, and to be separated from its attachment 
to the shaft of the ulna. 

Symptoms. — The symptoms of fracture of the coronoid process 
unaccompanied by luxation of the bones of the forearm are often 

Fig. 445. FiG- 446. 

■ 





FlG. 445. — Fracture of shaft of ulna, upper third. 
Fig. 446. — Fracture of shaft of ulna, lower third. 

indefinite. A definite diagnosis may be made, if there is localized 
pain and tenderness, increased by flexion at the elbow, local swelling, 
retention of the normal landmarks about the elbow, and a suggestion 
of crepitus on deep palpation over the coronoid. A radiographic ex- 
amination will clear up doubt. When there is present a dislocation of 
both bones posteriorly, fracture of the coronoid process may be diag- 
nosed by the comparative ease with which a recurrence of the disloca- 
tion is reproduced when the elbow assumes a partially flexed position. 
Treatment. — In fracture accompanied by dislocation, the latter con- 
dition should be reduced by traction with counter-traction, followed by 
attempts to* extend the joint and suddenly flex it. After reduction the 



374 



TREATISE ON FRACTURE^ 



forearm is carried to a position of hyperflexion. This position should 
be maintained for from two to three weeks, using the form of dressing 
described under fractures of the lower end of the humerus, and then 
may be kept in flexion greater than a right angle for about two weeks 
longer. When there is no dislocation present, there is generally little 
displacement of the coronoid fragment. In this condition the arm and 
forearm should be immobilized at a right angle on an internal or an- 
terior angle splint for three to four weeks. Very slight passive and 
active motion should, as in all fractures, be started early, but not be 
more than moderatelv indulged in until the end of four weeks. Com- 




Fic. 447. — Fracture of shaft of ulna, middle third. 
Fig. 448. — Multiple fracture of shaft of ulna, lower third. 

plete or nearly complete immobilization is perhaps more essential in 
this than in other fractures, so that anatomical apposition of the frag- 
ments is maintained, callus formation thus lessened, and therefore the 
possibility of interference in subsequent joint function decreased. If 
fibrous union only is obtained and there is marked interference with 
flexion of the elbow, resection of the detached fragment may be 
necessary. 

Results. — The after-results are generally favorable not only for 
union but also for subsequent return of full function. 

Fractures of the Shaft of the Ulna — Etiology. — Isolated fractures 
(Figs. 445-448) of the shaft of the ulna are usually the result of 



FRACTURES OF THE RADIUS AND ULNA 375 

direct violence, generally received by a fall directly on the pos- 
terior surface of the ulna or by a blow being received with the arm 
uplifted to protect the body or head. This is the so-called "parry 
fracture." Fractures by indirect force, such as a fall upon the hand, 
are extremely rare, as are also fractures by violent bending, torsion, 
pronation, or supination. When the fracturing force is severe, the 
fracture may be multiple or compound. A not uncommon complica- 
tion of fracture of the shaft of the ulna is an anterior dislocation of 
the head of the radius. This complication is considered by Helferich 
and Dorfler to accompany fractures of the shaft only when the frac- 
ture involves the upper third of the ulna. Oberst and also Wilms do 
not coincide in this view, and report cases in which the fracture in- 
volved the middle third of the ulna. This lesion is most frequently the 
result of a direct blow received upon the posterior aspect of the outer 
surface in the upper or middle thirds of the shaft of the ulna. 

Displacement. — In uncomplicated fracture of the ulnar shaft, the 
presence or absence of displacement is dependent upon the degree of 
the fracturing force, the nature of the fracture, and its position. Study 
of radiographs and patients seems to show that the displacement of 
the fragments is never uniform. There is doubtless a certain tendency 
for the lower fragment to be displaced toward the radius in complete 
fractures by the pull of the pronator quadratus muscle. An important 
factor, however, in producing this displacement is the weight and 
position of the hand held in ulnar adduction, which tends also to throw 
the upper end of the lower fragment toward the radial shaft (Fig. 
449). In incomplete fracture the angle of deformity is generally 
toward the radius. 

Symptoms. — The symptoms of incomplete fractures may be 
limited to localized swelling, ecchymosis,. pain and tenderness on pres- 
sure, especially on attempting to squeeze the shafts of the ulna and 
radius together. No deformity may be present. Crepitus is neces- 
sarily absent. In complete fractures there will generally be noted 
localized swelling, ecchymosis, pain, crepitus, deformity, inability to 
use the forearm, and marked pain on attempting forcibly to extend 
the forearm. Shortening will be absent unless there is an accompany- 
ing dislocation of the head of the radius, when it may occur. Radio- 
graphic diagnosis is important in obscure cases. 

Treatment. — The reduction of the fragments is best obtained by 
direct manipulation, and in fractures of the middle and lower thirds 
by firm and marked ulnar abduction of the hand in a position of semi- 
pronation. In fractures of the upper and middle thirds, immobiliza- 
tion may be obtained by the use of a right-angle anterior angular 
splint, and in fractures of the lower third by the use of an anterior 
and a posterior splint, which carries the hand in marked ulnar abduc- 



376 



TREATISE ON FRACTURES 



tion if much inward displacement of the upper end of the lower frag- 
ment is present. This position tends to force the upper end of the 
lower fragment away from the shaft of the radius. When no displace- 
ment of fragments is present in fractures of the middle or lower thirds 
and in fractures that are incomplete, a palmar splint suitably padded 
may be applied, extending from the fold of the elbow to the midmeta- 
carpal region with the hand supinated. Light massage and passive and 
active movements very moderately employed may be begun at the end 
of a week or earlier. Retentive splints may be removed permanently 
by the end of the fourth week. Gypsum contour splints moulded to 
the forearm, or aluminum sheets, 3 inches wide and Vie g au b e > lightly 
padded are very satisfactory for external fixation. 




Fig. 449. — Drawing to show type of displacement in fracture of the shaft of the ulna from direct violence. 

When fracture of the upper part of the shaft of the ulna is com- 
plicated by a dislocation of the head of the radius the latter should be 
reduced by traction, counter-traction and manipulation first; the frac- 
ture should be reduced and the parts immobilized on an anterior right- 
angle splint with the forearm in supination. Occasionally exposure of 
tbe fracture and direct fixation are demanded. 

Results. — Union occurs as a rule in three to four weeks. Non- 
union is rare, and union with deformity, if reduction is obtained, is 
unusual. 

Isolated Fractures of the Radius 

Statistics. — Plagcmann's statistics of 1393 cases of fracture, con- 
firmed by radiogram, show 71 (5.24 per cent.) involving the radius. 



FRACTURES OF THE RADIUS AND ULNA 



377 



Of these, 23 cases (1.65 per cent.) were of the head or neck; 12 cases 
(0.25 per cent.), fractures of the shaft; and 38 cases (2.72 per cent.), 
fractures of the lower end of the radius. 

Fractures of the Head of the Radius. — Radiography has 
shown that this formerly supposed rare fracture occurs with com- 
parative frequency. Recent literature and a study of a collection of 
radiographs in hospitals will show fracture of the head and neck of 
the radius to be not unusual. 





of fragments, 
ragment; complicated by frac- 



Fig. 450. — Fracture of the head of the radius. No displacemenl 
Fig. 451. — Fracture of the head of the radius, slight displacement of fragrr 
ture of coronoid process of the ulna. 



Etiology. — Fracture of the head of the radius may result from 
various injuries. The most common lesions are those caused by 
indirect violence, such as a fall upon the prone hand with the elbow in 
full extension, a violent abduction of the forearm, and as a complica- 
tion of a posterior dislocation of both bones of the forearm, and those 
due to direct violence, such as a blow or a fall upon the head of the 
bone. 

Varieties. — Fractures of the head of the radius (Figs. 450—453) 
are intracapsular. The fracture may be longitudinal, wedge-shaped 
and diagonal; also multiple or impacted. The position and form of 



378 



TREATISE ON FRACTURES 



the fragments are dependent upon the character of violence. Frac- 
tures associated with dislocation usually show a line of fracture in- 
volving a portion of the upper rim of the head ; those caused by violent 
abduction are situated, as a rule, on the outer rim. Fractures due to 
transmitted force through the forearm and to falls upon the palm of 
the hand may show a multiple fracture or the fragment may be im- 
pacted. Fracture of the epiphysis or through the epiphyseal cartilage 
is occasionally seen. 





had Iktu reduced. 



Displacement. — The fragment rarely becomes detached, being held 
by a portion of intact periosteum. Impaction of the fragment is often 
seen. It may, however, become displaced downward, and outward or 
backward, and unite with the neck of the radius ; it may at times stimu- 
late a fracture of the coronoid process of the ulna. When union of 
the fragment occurs, if it be not impacted, a certain amount of perma- 
nent displacement is frequently present. 

Symptoms. — The most noteworthy symptoms of fracture of the 
head of the radius are pain and tenderness over the region of the head, 
increased by passive pronation and supination of the forearm; impair- 
ment of voluntary pronation, supination, flexion and extension; broad- 



FRACTURES OF THE RADIUS AND ULNA 



379 



erring of the head of the radius; and moderate swelling of the elbow- 
joint. Crepitus is present, if the fragment is not impacted; it is 
elicited when the forearm is pronated and supinated, while direct pres- 
sure is made with the examiner's thumb over the radial head. (Dislo- 
cation of a misplaced fragment may be at times detected by palpation.) 
Associated injuries, such as dislocation of the bones of the forearm, 
and fracture of the external con- 
dyle or epicondyle, will be recog- 
nized by their usual symptoms. 
The use of the X-ray is very essen- 
tial for a proper diagnosis of these 
fractures, and also in the diagnosis 
of dislocation of the head of the 
radius (Figs. 454-456). 

Treatment. — T he form of 
treatment will depend in a great 
measure upon the radiographic 
findings. When it is found that 
the fracture is fissured in type, 
with little or only moderate dis- 
placement of the fragments, good 
functional result should be ob- 
tained by non-operative methods. 
The same may be said of fractures 
in which the fragments are im- 
pacted. Such lesions may be im- 
mobilized on an anterior right 
angular splint with the hand in 
supination or on an internal an- 
gular splint with the hand in pro- 
nation for three to four weeks. 
The supine position is probably as 
a rule the better After the first 
week gentle massage should be in- 
stituted, and the end of the 
third week this should be supple- pig. 454.- 
mented by passive motion 

When there is considerable displacement of fragments, and when 
there is marked comminution of the bone, union is likely to occur with 
the formation of considerable callus, which will probably interfere 
with flexion, and extension of the elbow, and especially with pronation 
and supination of the radiohumeral joint. Often non-union occurs, 
and the separated fragments then may greatly interfere with the normal 
motions. In these cases the best results will be obtained by arthrotomy 




380 



TREATISE OX FRACTURES 



for the removal of the separated fragments or resection of the broken 
head of the radius. The loss of the radial head, if the neck is not 




Figs. 455 ant> 456. — Posterior luxation cf the radius and uln; 
off hay wa?on three weeks previously. Fig. 455 shows the extent of forced flexion ope 
See Fie- 454 for rontgenogram. (Courtesy of Dr. Morris Booth Miller.) 




FlC. 457. — Fracture of the upper radial epiphysis. Boy fell over 
arms extended. 



le of bicycle on palms with 



removed and the orbicular ligament left intact, is not a cause of much 
functional disability. 

Results. — T. T. Thomas report- [8 cases treated conservatively as 
follows: union without deformity, 3 cases; union with deformity, 5 



FRACTURES OF THE RADIUS AND ULNA 



381 



cases; non-union, 8 cases; bony ankylosis, I case; fibrous ankylosis, 
i case; and greatly impaired function, 2 cases. Hitzrot reports 19 
cases. Of these, in 15 instances treated non-operatively there was loss 
of half of rotation in all but 2 cases ; of 4 operative cases, in which the 
fragment or part of the head was removed, rotation was better pre- 
served and was nearer normal in those in which the entire head was 
excised. 

Separation of the Upper Radial Epiphysis. — This condition is 




/ 




extremely rare. Its presence can scarcely be demonstrated even by 
the radiogram, unless there be marked separation. The centre for this 
epiphysis appears as a single centre about the fifth or sixth year, and 
becomes completely ossified about the seventeenth or eighteenth year. 
Fractures of the Radial Epiphysis. — More common than sepa- 
ration of the radial epiphysis is its fracture (Fig. 457). This con- 
dition, however, is also rare. Fracture usually occurs through the 
upper portion of the epiphysis with the fracture line continuing into 



382 TREATISE ON FRACTURES 

the diaphysis. Impaction of the fragments is the rule. The case illus- 
trated is bilateral and resulted from a fall over the handle-bars of a 
bicycle. The boy, who was thirteen years of age. fell on both palms 
with the elbows in full extension. Immobilization on an internal right- 
angle splint for three weeks was followed by perfect functional results. 

Fracture cf the Neck of the Radius. — Of 23 cases of fracture 
of the head and neck of the radius observed by Plagemann, 4 alone 
involved the neck. Of r8 cases of fracture of the head and neck of 
the radius studied by the authors in a collection of radiographs. 9 
involved the neck of the radius alone. 

Etiology. — Fracture of the neck of the radius (Figs. 458 and 459 ) 
results from indirect force, like falls upon the palm of the pronated hand 
with the elbow in extension, and forces causing severe abduction of 
the elbow. From the greater frequency with which fractures of the 
neck are associated with posterior dislocation of the ulna or with frac- 
ture of that bone, it seems probable that the lesion is more often the 
result of greater violence than is fracture of the radial head. Fracture 
of the coronoid process is also at times observed in conjunction with 
fracture of the neck of the radius. 

Displacement. — The fracture may be transverse, oblique, or com- 
minuted. Impaction with slight displacement occurs frequently. In 
other instances the fracture is attended with considerable displace- 
ment of the upper fragment, mainly characterized by partial rotation 
outward and forward. The line of fracture may be both intra- and 
extra-articular. Fracture of the head of the radius may also involve 
the neck when the line runs in a ventral direction. 

Symptoms. — In fractures of the neck of the radius the most char- 
acteristic symptoms are marked swelling in the region of the head and 
neck, impairment of pronation, supination, and flexion. If the frac- 
ture is not impacted there will be noted crepitus at the seat of fracture 
on passive pronation and supination, with failure of rotation of the 
head of the radius. In addition there will be localized pain, swelling, 
tenderness, and in some cases noticeable deformity on palpation. In 
case> the result of severe direct violence or wrenching, there may be 
marked swelling of the soft pans with ecchymosis. A radiograph 
should be made in suspected cases. 

Treatment. — The treatment of these cases depends upon the variety 
of fracture and the character of the displacement of the fragments. 
In impacted fractures with little displacement, good results may be 
obtained by immobilization for from three to four weeks upon an 
anterior right-angle splint Gentle massage should l>egin at the end oi 
the first week, and be followed by very gentle passive motion at the 
end of the third week. When impaction is not present and but mod- 
erate displacement of the upper fragment has occurred, attempts at 



FRACTURES OF THE RADIUS AND ULNA 



383 



reduction should be made by manipulation; if reduction is obtained, 

immobilization as above outlined should be the method of procedure. 

The maintenance of reduction should be proved by radiography. If 

reduction is impossible, or its maintenance difficult, or if comminution 

of the fragments is present, arthrotomy and resection of the upper 

fragment should be performed. 

Results. — Union occurs as a rule within three or four weeks. Non- 
union is not as frequent as in fractures of the radial head. Hitzrot 

reports ten cases of fracture of the neck of 

the radius treated by non-operative means 

with loss of about 25 per cent, of rotation. 
Isolated Fractures of the Shaft of the 

Radius (Figs. 460-463.) — Fracture of the 

shaft of the radius was observed by Plage- 

mann 12 times in 73 such radial lesions, while 

isolated fractures of the shaft of the ulna were 

observed 15 times in 31 cases of ulna fracture. 

These statistics as to the relative frequency 

are similar to those generally reported. Of 

these 12 isolated fractures of the shaft of 

the radius Plagemann gives the localization 

as follows : 2 transverse fractures of the upper 

third; 3 oblique fractures at the junction of 

upper and middle thirds ; and 7 fractures near 

the junction of the middle and lower thirds. 
Etiology. — Fractures of the shaft of the 

radius are generally the result of direct vio- 
lence. Indirect violence may occasionally pro- 
duce the injury; especially when the force is 

applied in a longitudinal direction as in cases 

reported by Falkson. Muscular action easily 

produces a fracture. The line of fracture is G 

usually oblique, spiral, or irregularly trans- f 

verse. 

Displacement. — As a rule the displacement of fragments is not 
great. Their position, however, is dependent upon the location of the 
fracture, its variety, and upon the action of the attached muscles, par- 
ticularly the biceps, the pronator teres, and the pronator quadratus. 
The upper fragment of the radius in fractures above the insertion of 
the pronator teres is inclined to become supinated by the action of the 
biceps (Fig. 464) and pulled upwards. Below the insertion of this 
muscle up to the tubercle the displacement tends to cause angulation 
toward the shaft of the ulna, due to the pull exerted by the pronator 
teres and quadratus. When this fracture is below the insertion of the 



Fracture of the shaft 
adius, upper third. 



384 



TREATISE OX FRACTURES 



pronator teres, the lower end of the upper fragment is apt to be pro- 
nated, and the hand may need to be pronated during treatment. \\ "hen 





Fig. 461. — Fracture of the shaft of the radius, junction of middle and upoer thirds. 
Fig. 462. — Fracture of the shaft of the radius, middle third. 
Fig. 463. — Fracture of the shaft of the radius, lower third. 




Fig. 464. — Drawing to show the effect of the triceps muscle in causing displacement of the upper 
fragment in fracture of the upper third of the shaft. (Made after rontgenogram. Fig. 460.) 

tbe fracture is just above the square pronator the lower fragment may 
by spasm be pronated and drawn towards the ulna (Fig. 465). 

Symptoms. — As most of the fractures are the result of direct vio- 



FRACTURES OF THE RADIUS AND ULNA 



385 



Ience, there is generally moderate swelling and ecchymosis of the over- 
lying soft parts, localized pain, tenderness on pressure, abnormal 
mobility, deformity, and crepitus. When the thumb is placed over 
the head of the radius, and passive pronation and supination of the 
hand made, it will be found that the head of the radius fails to rotate 
unless impaction of the fragments is present or the fracture is incom- 
plete. In very muscular subjects the diagnosis may be made with cer- 
taint)^ only with the help of the radiogram. 

Treatment. — Reduction of fragments may be accomplished by ex- 
tension, counter-extension and local manipulation of the fragments. 
In fractures below the middle and in the lower third, when the upper 



1 vpm 












11 


•■ 










\ ' wv& 














HP^SI 






-r2glS 


j 




^^l^fc— 


— ' " - — 














"ZfrvfiffJ/fi 

















Fig. 465. — Drawing to show the action of the pronator quadratus 
ment of the lower fragment in fracture of the lower third of the radius 
Fig. 462.) 



Ascle in producing displace- 
(Made after roentgenogram, 



end of the lower fragment is markedly inclined toward the ulna, re- 
duction may possibly be aided by marked ulnar adduction of the hand 
in addition to traction and counter-traction. After reduction the parts 
should be immobilized upon carefully padded anterior and posterior 
splints, with the hand in a position midway between pronation and 
supination, or fully supinated. In fractures of the upper third or above 
the insertion of the pronator teres muscle, the tendency toward supina- 
tion of the upper fragment due to the pull exerted by the biceps muscle 
should be remembered ; and in this form the parts should be immobi- 
lized upon a right-angle anterior splint or moulded gypsum splints with 
the forearm in full supination. Immobilization with frequent re- 
25 



386 TREATISE ON FRACTURES 

moval of dressings should be continued for three or four weeks. In 
cases in which satisfactory reduction cannot be accomplished or where 
non-union persists, the seat of fracture should be exposed, reduction 
accomplished, and a direct fixation by plate, wire, absorbable lashings, 
fascial envelopment, or inlaying of bone graft adopted. 

Fractures of the Lower End of the Radius.— 'Fractures of the 
lower end of the radius constitute a large percentage of all frac- 
tures. Plagemann's statistics based upon radiographic diagnosis of 
1393 cases show that there were 38 (2.72 per cent.) cases of fracture 
of the lower end of the radius. 

The term Colles's fracture has by unfortunate custom been used for 
a long time to designate all fractures occurring at the lower end of 
the radius. The more closely, however, fractures here are studied, the 
more fully is the fallacy of using the term indiscriminately shown. 
There are so many varieties of fracture of the lower end of the radius 
possible that the term " Colles's fracture " and even that of " classic 
fracture " should be avoided. Many of these cases are clinically 
similar, and the form of treatment is more or less uniform. 

Etiology. — Fractures of the lower end of the radius may be the 
result of falls upon the palm of the hand in a position of pronation, of 
falls upon the dorsal surface of the flexed wrist, by direct violence 
(chauffeur's fracture), and by the pull exerted by the anterior or pos- 
terior ligaments in a position of hyperextension or hyperflexion. In 
the majority of fractures of the lower end of the radius it may be gen- 
erally stated that they are the result of a fall upon the palm of the 
hand which allows transmission, through the carpus to the radius, of 
the force due to the weight of the falling body and its velocity. In 
addition, the pull of the anterior carpal ligament in fractures occurring 
with the hand in a position of hyperextension, or the posterior carpal 
ligament in fractures with the hand in a position of hyperflexion, is a 
factor in the production of these fractures. The agency of the liga- 
mentous attachments is clearly shown in the sprain-fractures seen 
about the wrist-joint. Fractures by direct violence are rare, except in 
the variety known as chauffeur's fracture ; this injury is produced by 
the cranking handle of the gasoline engine in back-firing striking 
against the posterior part of the wrist-joint. All injuries resulting 
from this back-firing are not necessarily fractures of the lower end of 
the radius, for fractures involving the carpal and metacarpal bones 
have been thus caused. Sprain- fracture of the radius may result from 
back-firing by throwing the hand into a position of forcible hyperex- 
tension. In fractures produced by falls upon the hyperextended hand, 
the line of break, its direction, and the degree of displacement of the 
lower fragment depend to a great degree upon the amount of prona- 
tion present at the time of the fall. In falls forward the degree of 



FRACTURES OF THE RADIUS AND ULNA 387 

pronation is generally marked, while in falls to the side or backward 
the impinging hand generally is in a position of marked supination or 
semi-pronation. 

Varieties. — Study of many radiograms and a small but well-illus- 
trated group of pathological specimens has seemed to justify the fol- 
lowing division of fractures occurring at the lower end of the radius : 

i. Irregular, transverse fracture of the radius and ulna (Figs. 466 
and 467). It consists of an irregular, transverse fracture line of both 
radius and ulna, situated from one to one and a half inches above the 
articular surface of the radius. It is mentioned here only on account of 
the clinical resemblance which it bears to the classic fracture of the 
base of the radius. It is most frequently observed during childhood. 

2. Fracture of the styloid process of the radius (Figs. 468-471). 
The following varieties may be recognized : 

(a) Fracture of the tip of the process. 

(b) Fracture of the tip of the process with fracture of the shaft 
of the ulna. 

(c) Fracture of the base of the process with fracture of the scaph- 
oid. This fracture is relatively rare. It is the result of a fall upon 
the hand in a position of full pronation. It may be associated with 
fracture of the carpal bones, particularly the scaphoid. Infrequent 
forms of fracture of the radial styloid are those resulting from mus- 
cular pull with the hand in forced hyperflexion seen in the infrequent 
sprain- fractures. 

3. Irregular, transverse fracture with posterior and at times out- 
ward (radial) displacement of the lower fragment (Figs. 472-477). 
It is often unwisely called Colles's fracture of the radius, although 
Colles did not describe the usual situation of the fracture line, but placed 
it }i to 1 inch further from the radio-carpal joint. Formerly the frac- 
ture line in this fracture was considered as running obliquely upward 
and backward. The line varies within certain limits, but it is gen- 
erally near the point where the cancellous bone of the base is rapidly 
replaced by compact bone. Obliquity of direction of the fracture line 
is not necessarily characteristic, nor is the exact distance of the same 
above the articular surface. The principal characteristics of this well- 
known fracture are an isolated fracture of the lower end of the radius, 
with the fracture line generally transverse, about three-eighths to three- 
fourths of an inch above its distal extremity, with posterior and at 
times outward (radial) displacement of the lower fragment. Impac- 
tion of the fragment is often present, as is also outward displacement 
of the wrist, and rotation posteriorly of the articular surface of the 
lower end of the radius. The types of this " classic " fracture may 
be described thus : 




1 Pig. 467. B 

FlC. 4*6— Low transverse Fracture <-( radius and ulna. Clinical resemblance to Colles's fracture. 
Fig. 467.— Low transverse fracture of radius and ulna. Marked displacement of lower fragments. 




Fig. 468.- 

Fig. 469.- 

FiG. 470. — Fracture of the 

Fig. 471. — Separation of li 



t70. Fig. 471. 

-Fracture of the tip of the styloid process of the radius. 

-Fracture of the base of the styloid process of the radius. 

base of the styloid of the radius and of the styloid of the ulna. 

wer epiphysis of radius with fracture of outer part of the diaphysis, 

sembling in a great degree fracture of the styloid process. 



390 



TREATISE OX FRACTURES 



(a) Those of adult life. 

i 6 i Those of childhood. 

(c) Associated with fracture of the styloid process of the ulna. 

(d ) Associated with comminution of the lower fragment. 

(r ) Associated with fracture of the neck of the ulna. 

4. Irregular, transverse fracture with anterior displacement of the 
carpal fragment : sometimes called reversed Colles's fracture and 
Smith's fracture (Figs. 478 and 479). At times the line of fracture 
runs obliquely upward and forward. This lesion was first recognized 
by Smith and later Roberts collected 24 cases and 31 specimens. 

5. Separation of the radial epiphysis (Figs. 480-483). 
(a) With fracture of the diaphysis. 




1 b 1 With fracture of the anterior edge of the diaphysis. 

( c) With fracture of the posterior edge of the diaphysis and ac- 
companying; separation of the ulnar epiphysis. 

Isolated separations of the radial epiphysis arc very rarely seen. It 
is doubtful if a pure epiphyseal separation ever occurs, excepting in 
very young children. The usual lesion consists in an accompanying 
fracture of either the posterior or anterior edge of the diaphysis. plus 
the separation of the epiphysis. The periosteum remains intact on the 
^iflc opposite to the detached fragments. The lesion closely resembles 
the classic fracture at the lower end of the radius, except for the ab- 



FRACTURES OF THE RADIUS AND ULNA 391 




Fig. 474. — Transverse fracture of the lower end of the radius with outward and posterior dis- 
placement of the lower fragment. This type gives the abduction and "silver-fork" deformity typical 
of many Colles's fractures. 



392 



TREATISE OX FRACTURES 



sence of impaction, outward displacement, and loss of shortening of 

the distance between the radial styloid and the upper end of the bone. 

6. Fractures through the carpal articular surface with separation 

of the posterior articular edge. This is the true but unusual Barton's 




X 



Fig. 473. — Old united Colles's fracture with ununited fracture of the styloid process of the ulna. 
Note abduction and posterior displacement of lower part of radius. This fracture was never properly 




A B A B 

Fir,. 476. — Atypical type of fracture of lower end of radius. Note comminution of fragments. Not 

a typical form of Colles's fracture. 
Fig. 477— Healed fracture of lower end of radius. Note posterior displacement and rotation of the 

lower fragment. Typical form of unreducedColles's fracture in old people. 

fracture (Figs. 484 and 485). This fracture may have associated with 
it a fracture of the ulnar styloid, or a fracture of the internal articular 
edge as well. Such injuries are usually the result of direct violence. 



FRACTURES OF THE RADIUS AND ULNA 



393 



7. Fractures through the carpal articular surface with separation 
of the anterior articular edge. This may be designated reversed Bar- 
ton's fracture (Fig. 486). They may be the result of direct violence 
or be produced by forcible hyperflexion, in which instances they may 
be well termed sprain-fractures. 

8. Green-stick fractures (Figs. 487 and 488). Several varieties of 
green-stick fractures occur : 

(a) Involving the entire thickness of the bone. 

(b) Involving only a portion of the cortex (cortex or infolding 
fractures). 




(c) Involving the entire thickness of the shaft accompanied by a 
fracture of the ulnar styloid or shaft. 

(d) A form of cortex fracture which is only recognizable after 
four to five weeks have elapsed, when it will be noticed by a deposit of 
cancellous tissue along the course of previously detached periosteum. 
In this form of fracture there is no appreciable bony lesion discover- 
able with the radiogram at the time of the injury. 

Of particular interest is the infolding fracture. It is observed in 
children between the ages of seven and fourteen. The lesion consists 
of bending; outward of the cortex and occurs where the resistant 



394 



TREATISE ON FRACTURES 





fracture, or Smith's fracture.) 



Fig. 480. Fig. 481. 

lift f 

A B A B 

Fig. 480. — Separation of lower radial epiphysis with posterior displacement of epiphysis, and a small 

fragment of the diaphysis. 

Fig. 481. — Separation of lower radial epiphysis and fracture of the anterior portion of the lower 

edge of the diaphysis, with anterior displacement of the lower fragment. (A reversed Colless type.) 

cortex meets the flexible cortex. The position of this fracture varies 
with the age of the child. The younger it is, the nearer is the line of 
fracture to the epiphysis. In childhood the cortex is still flexible, and 
as a result of impaction and slight flexion, the cortex bulges outward. 



FRACTURES OF THE RADIUS AND ULNA 



395 



9. Longitudinal fissure fracture (Figs. 489-493). Irregular longi- 
tudinal Assuring may be observed, without transverse fracture, with 
transverse fracture, and with oblique fracture. This variety is rather 
unusual and is generally the result of transmitted force directed up- 
ward through the hyperflexed palm and carpal bones. A rare form is 
double longitudinal lines united by a transverse line resembling the 
Greek letter n. 

10. Isolated oblique fracture running downward and outward 




Fig. 482. — Separation of lower radial epiphysis with posterior displacement of the lower fragment. 



(Fig. 494). This lesion may have associated with it comminution and 
Assuring of the upper fragment. 

11. Isolated oblique fracture running downward and inward 
(Figs. 495 and 496). 

12. Transverse Assuring or incomplete fracture without displace- 
ment in the adult. 

13. Sprain-fractures (Figs. 497 and 498). A variety of lesions 
may be classified under this term. These fractures are the result of 
rapid, forcible hyperflexion, hyperextension, or hyperadduction. The 



TREATISE ON FRACTURE; 

■ 





— Fracture through the carpal articular 

-re through the cat -race with separa- - - "ir edge. 



he detachment of par: rtex at the point of 

attachment of ligaments forcibly stretched. 



FRACTURES OF THE RADIUS AND ULNA 



397 



14. Chauffeur's fracture (Figs. 499-501). Under this term are 
classified those fractures received while cranking a gasoline motor, 
when back-firing occurs. They are the result of direct violence from 
the starting handle hitting the back of the hand or forearm, or are due 
to forcible hyperextension. They differ in character, depending upon 
the mode of production. When due to direct violence, a transverse 
fracture usually results. When due to forcible hyperextension, the 
fracture partakes of the nature of a sprain-fracture. The location of 
the lesion depends upon the part 
struck when due to direct vio- 
lence and may involve the radius 
alone, the radius and ulna, the 
carpal bones, or the metacarpals. 
When due to hyperextension the 
lesion usually involves the anter- 
ior articular edge or the styloid 
process. 

The above classification of 
fractures occurring at the lower 
end of the radius is sufficiently 
comprehensive to cover practi- 
cally all forms in this region. 

Symptoms. — It may be stated 
that unnecessary roughness is 
often used in endeavoring to 
make a diagnosis of fracture at 
the lower end of the radius. The 
necessity of pain-giving manipu- 
lation may be limited in the ma- 
jority of cases by careful obser- 
vation of the part and compari- 
son with the other forearm 
Crepitus is a symptom which is 
often absent and it causes only 
pain to the patient to endeavor to 
demonstrate its presence. Many of these fractures are impacted and 
some comminuted, and crepitus is not demonstrable without undue 
force. In the classic fracture, when severe, inspection will show general 
swelling about the wrist-joint and even extending several inches above it. 
On the flexor surface there will be loss of the normal radial arch, and 
01-1 the extensor surface swelling over the upper end of the lower frag- 
ment extending downward for a variable distance, presenting from a 
lateral position the so-called "silver-fork" deformity (Fig. 502). 
When the backward displacement is marked, the dorsal edge of the 




Fig. 486. — Fracture through the carpal articular 
surf ace with separation of the anterior articular edge. 
(Reversed Barton's fracture.) 



398 TREATISE OX FRACTURES 

lower fragment can be felt as a ridge about half an inch above the 
wrist-joint. This is best done by running a finger of the surgeon 
down the posterior surface of the radius. In addition to this de- 
formity, there is generally abduction of the hand and broadening of 
the wrist (Figs. 503-505 ). Palpation of the parts shows loss of the 
radial arch at its lower flexor region and at times prominence of the 
lower end of the upper fragment on the flexor surface. Prominence of 
the lower fragment occurs posteriorly with rotation of the same back- 




FlG. 487. — Incomplete (green-stick) fracture of the lower end of the radius. Typical cortex or infold- 
ing fracture. Entire thickness of bone is not involved. 

ward, so that the transverse plane of the articular surface of the lower 
end of the radius is rotated from ten to thirty degrees. Posteriorly 
there is a loss of prominence of the styloid process of the ulna, with a 
corresponding prominence of the same on the flexor surface of the 
wrist, so that it is brought into a closer relation with the pisiform bone. 
Comparison of the radial styloid with that of the ulna will show that 
it is carried toward the elbow and is therefore on a line with, or a 
little above, the ulnar styloid. Normally it occupies a lower plane 




Fig. 489- 




Figs. 489 and 490.— Types of longitudinal fissure fracture of the lower end of the radius. 



FRACTURES OF THE RADIUS AND ULNA 



401 



(Fig. 506). In many cases there is not only a posterior rotation and 
displacement of the lower fragment, but also an external or radial 
abduction of the carpus and fingers. The hand and fingers are held 
in semi-flexion, and full flexion is possible to a less degree relatively 
than full extension. 

Impaction of fragments is present in many instances, so that 
crepitus and abnormal mobility are not readily determined The swell- 




FlG. 49S, 

Fig. 496. 



-Isolated oblique fracture of the lower end of the radius with the line of fracture running 

downward and inward. 
-Isolated oblique fracture of the lower end of the radius with the line of fracture running 
downward and inward; also a fracture of the lower third of the ulna. 



ing noticed in all fractures of the lower end of the radius may at times 
be augmented by an effusion of serum within the tendon sheaths, the 
presence of hemorrhage outside the sheaths, and effusion within the 
wrist-joint. The line of the radiocarpal joint is a curve with con- 
vexity upward in the normal condition. Pressure here will often dif- 
ferentiate a mere sprain or rheumatic arthritis from fracture above 
the joint, because the tenderness elicited will be over the curved joint 
line instead of over the base of the radius. 
20 



402 



TREATISE OX FRACTURES 



In the non-classic fractures of the lower end of the radius, the 
symptoms above described will be wholly or in part absent, and 
when present may show specific differences. Many of these fractures 
are unaccompanied by deformity or crepitus, the most noticeable symp- 
toms being localized swelling and localized tenderness on pressure. 
This occurs when there is little displacement and little laceration 
of periosteum. In some cases, notably the transverse fractures with 
impaction and little deformity, the infolding fractures and the 




Types of sprain fractures of the 1 



■ end of the radius. 



llv bv the 



sprain-fractures, there may be bony lesions discoverable 
radiogram. 

In injuries about the wrist-joint, lateral and anteroposterior 
radiograms should be taken, if practicable, in all cases of doubtful 
diagnosis, and also when it is necessary to determine the degree of 
replacement of the fragments after reduction. 

Diagnosis. — The diagnosis of fractures at the lower end of the 
radius is to be made by careful inspection, and palpation and the radio- 
gram. Deformity when present is usually typical. The most striking 





Fig. soo. — Chauffeur's fracture. Line of fracture is transverse at lower end of radius, also involves 

styloid of radius; also a fracture of styloid of ulna. 

Fig. 301. — Chauffeur's fracture by muscular action; a small portion of bone is torn out of outer part 

of radius at base of styloid process. 



404 



TREATISE OX FRACTURES 



changes are absence of the radial arch, broadening at the wrist, rota- 
tion, and at times displacement of the lower fragment posteriorly, com- 
bined with localized swelling. There is generally effusion into the 
tendon sheaths. Lateral displacement of the hand, the so-called bay- 
onet deformity, is frequently present, particularly in people of ad- 






FlGS. 503 and 504. — Old fracture of radius (Colles's type) and of styloid process of ulna with 
rapture of radio-ulnar ligaments. Note broadening of wrist, abduction deformity and prominence 
of styloid process of ulna. (Courtesy of Dr. John H. Jopson.) 

vanced life with comminution of the lower fragment. In doubtful 
cases the diagnosis may always be made by the use of the radiogram. 

The ridge caused by the upper border of the lower fragment usually 
may be felt with the tip of the finger about a half inch above the wrist- 
joint. The line of the joint is a curved line convex upward running 
from radial styloid to the lower end of the ulnar styloid with the 
patient's hand pronated. Recollect that the ulnar styloid is towards the 
palmar surface of the ulnar border of the wrist. When there is much 



FRACTURES OF THE RADIUS AND ULNA 405 




■ end of radius and ulr 




Fig. 306. — Method of palpation to determine the 
the radius and of the ulna. Normally that of the radiu 



displacement radially the edge of the fragment may be felt as a ridge 
on the radial border above the wrist. 



406 



TREATISE OX FRACTURES 









6"2g 



if! 

■Cttj ft 



■S.-S 

** « S, 

x £■- 
|q2 



5 . * 





So 



If: 






FRACTURES OF THE RADIUS AND ULNA 407 

Differential Diagnosis (Fig. 507). — Conditions that may be con- 
fused with the classic fracture are backward and forward luxation at 
the radiocarpal articulation, mediocarpal luxation backward, chipping 
off at the posterior edge of the radius at the radiocarpal joint and of 
the anterior edge of the radius. 

In these instances the radiogram is of invaluable assistance in arriv- 
ing at a correct diagnosis. Careful comparative study of the anatom- 
ical relations of the two wrists will aid much. The test to discriminate 
between radiocarpal arthritis and fracture by pressure over the joint 
line has been mentioned. Fracture without displacement will be made 
evident by tenderness on pressure and will perhaps show within a few 
days a localized ridge of callus. It must be remembered that the 
uninjured wrist may be somewhat deformed by previous fracture 
forgotten by the patient. Recently such an instance occurred in the 
practice of one of the authors. The woman denied the receipt of any 
injury of the opposite arm, but the suspicion of the surgeon was 
confirmed by X-ray study. 

Treatment. — In the treatment of fracture at the lower end of the 
radius it is well to have a clear conception of the exact nature of the 
fracture before reduction is attempted. In the typical or classic frac- 
ture, without complicating lesions, however, reduction usually may be 
performed satisfactorily without a primary radiogram. This state- 
ment applies particularly to the fracture with backward displacement 
of the lower fragment. The most important task in the treatment of 
typical fractures at the lower end of the radius with posterior dis- 
placement of the basal fragment is to obtain complete reduction. To 
retain the fragments in their proper position after reduction, until union 
has occurred, is not very difficult. The vital mistake often made is 
not securing complete reduction. In many instances this will be se- 
cured only with the help of an anaesthetic, because the pain of forcible 
reduction is great. Primary anaesthesia with ether or momentary 
unconsciousness from nitrous oxide gas is all that is necessary. Bad 
results following this fracture are usually attributable to the surgeon's 
failure to secure reduction and not to faulty methods of immobilization. 

If the fragments are thoroughly reduced, the tendency to recurrence 
of the deformity is slight except when the lower fragment is much 
comminuted or the complicating fracture of the ulnar styloid or head 
permits displacement. After thorough reduction, the simplest form 
of retention will suffice in most cases, provided that the arch of the 
lower fifth of the radius on its flexor surface is thoroughly recon- 
structed. The existence of this arch-like contour in the normal radius 
is often forgotten. There are many methods of reduction which may 
be used in the reduction of fractures of the base of the radius. In 
many fractures here, notably the sprain-fractures, comminuted frac- 



408 TREATISE ON FRACTURES 

tures, and fractures of the radial styloid, reduction is accomplished with 
little effort and without anaesthesia. It is, however, in the most fre- 
quent typical and nearly transverse fracture that considerable effort 
at reduction is necessary. Firm impaction is present in a large number 
of instances. No one method of reduction is applicable to all cases. 

Frequently reduction may be accomplished by firmly seizing the 
forearm, with one hand at the junction of its middle and lower thirds 
for counter-traction, and making traction by grasping the wrist of the 
patient with the other hand, which should encircle his wrist-joint, with 
the thumb pressing upon the backwardly displaced lower fragment. 
The fragments should be disengaged by traction and counter-traction, 
aided perhaps by first increasing the deformity by forcible dorsal ex- 
tension at the seat of the fracture. Strong pressure with the operator's 
thumb will aid in forcing the lower fragment into place. After the 
fragments have been disengaged, marked flexion at seat of fracture is 
made, combined with adduction. This latter procedure will correct 
posterior displacement of the lower fragment, re-establish the radial 
arch, and overcome the abducted position of the lower fragment, which 
is so frequently present in the typical injury (Figs. 508-510). 

After the radial arch has been corrected, the undue prominence of 
the ulnar styloid changed, and rotation and adduction of the lower 
fragment accomplished, one may be reasonably sure of obtaining a 
good result if the corrected position of the lower fragment is main- 
tained until union has occurred. 

Maintenance of reduction may be accomplished by the use of any 
of several forms of dressing. A gypsum splint moulded to fit the 
dorsal or the flexor surface when the wrist is somewhat flexed can- 
not be improved upon. In reduced fractures with little tendency to dis- 
placement, a slightly padded, narrow wooden splint applied to the 
dorsal surface of the forearm and hand, extending from a few inches 
below the elbow to a point just above the metacarpophalangeal joints, 
will steady the fragments and be all that is necessary (Figs. 511 and 
512). This is due to the circumstance that the dorsum of the recon- 
structed radius is practically level (Fig. 513). This is not the case 
with the flexor surface of the radius, which is arched in its lower fifth. 
If a wooden splint is placed on the palmar surface, it must be covered 
with sheet-wadding and have a hard pad placed at its lower end to fill 
the normal radial arch. It should in many cases be supplemented by a 
posterior splint. The splints may be attached to the forearm and hand 
by thick strips of adhesive plaster one and one-half inches in width, 
the upper strip at the upper level of the splint, the second strip over the 
lower fragment, and the third strip, about one-half inch in width, 
should be applied to the lower end of the splint and hand (Fig. 514). 
Over the splint, forearm, and hand a snugly-fitting muslin bandage 



FRACTURES OF THE RADIUS AND ULNA 409 








-Method of reduction of classic fracture £ 
forward of the lower fragment, 



by forcible carrying 




FlG. 510- — Morton's method of reducing a Colles's fracture by sudden snapping of the lower 
fragment forward. The thumbs are placed on the posterior surface of the lower fragment, the inter- 
locked fingers of both hands on the anterior surface of the lower end of the upper fragment, and by a 
sudden snapping motion the lower fragment is carried forward with the hand of the patient. 

two inches in width should be applied and the part put at rest in a 
comfortably fitting sling. It is probably of little consequence whether 
the forearm and hand are kept in the semi-prone or the fully prone 
posture, if the reduction is complete and the radial arch maintained. 



410 



TREATISE ON FRACTURES 



In fractures in which there is marked tendency to repeated dis- 
placement of the fragments, anterior and posterior splints of bass- 
wood are applied by some. They should be of the same length as de- 
scribed above. Both splints should be pistol-shape, so as to maintain 
adduction of the lower fragment and hand. They are best described 
by the accompanying illustrations. The two splints should be care- 
fully padded with four to six layers of sheet-wadding and, in addi- 
tion, a pad of sheet-wadding should be placed on the flexor surface 
of the forearm to maintain the lower end of the upper fragment in 
its proper position and retain the normal radial arch (Figs. 515—517). 

Fic.su. 




jii and SI2.— Show application of posterior padded straight splint lor immobilization of 
fracture at the lower end of the radius when there is no tendency toward recurrence of the deformity. 

If reduction is complete and the wrist kept flexed, the extensor tendons 
will hold the lower fragment in place nearly always. A pad may 
be at times placed over the posterior portion of the lower fragment, 
but great care should be used in its application, as pressure sores are 
prone to develop if the dressing is at all tight. In many instances this 
pad is unnecessary. It is well to remember that in fractures, pressure 
from pads for the purpose of reducing deformity is dangerous. The 
splints should be held to the forearm and hand with three strips of 
adhesive plaster, as shown in the illustration, and over all a snugly- 
fitting muslin bandage should be applied. The forearm should be 
carried in a sling until union is firm. The use of strips of adhesive 



FRACTURES OF THE RADIUS AND ULNA 



411 



plaster around limbs to hold splints in position is fraught with danger, 
except in skilled hands, inflammatory swelling may unexpectedly 
occur, and cause injurious constriction. 

The treatment of these cases is well conducted with moulded con- 
tour splints of plaster-of-Paris. A plaster bandage should not be 
applied in a circular manner until swelling has subsided, but an 
anterior or a posterior splint should be moulded from gauze and 
gypsum, properly padded with a thin layer of sheet-wadding and applied 
to the part. The splints should be held in place with a gauze bandage. 
Whatever dressing is adopted, reduction of the fragments must first 




-ating the plane of the posterior aspect of the bones of the forea 




be secured, and in all cases the fingers should be allowed opportunity 
for active movements from the very beginning of treatment. 

As has been said above, splints may be applied with the hand in a 
position of semi-pronation or pronation, though even supination is 
not objectionable. Every fracture should be inspected not later than 
twenty-four hours after the application of the splint; the bandage 
should be removed, and the parts examined for areas of undue pres- 
sure, and the splint or splints reapplied. The surgeon should always 
remove the splints immediately and examine the parts if there is any 
evidence of undue swelling or cyanosis of the fingers. This precaution 
should be taken for pain, numbness, paresthesia, and for localized pain 



412 



TREATISE ON FRACTURES 

Fig. sis- 




in the region of the lower fragment or the hases of the second and 
third metacarpals posteriorly. If a moulded metal (Figs. 518 and 519) 
or gypsum splint is used on the palmar aspect of the forearm, it should 



FRACTURES OF THE RADIUS AND ULNA 



413 



extend as far as the middle of the palm, and the wrist should be 
partially flexed. 

The line of treatment here indicated is that to be used in practically 
all recent fractures of the lower end, or base, of the radius. When the 
ulnar styloid is broken from its shaft, as a complication of the break 
of the radius, it is well to deflect the hand a little towards the ulnar 
border of the forearm by the retentive dressing. A small pad against 
the broken process or a " thumb dent " in the gypsum splint may aid in 
holding the little fragment in place. Union is apt to be fibrous, proba- 
bly because it usually is not kept in contact with the shaft. This defect 
is not very important. 




• 



4*M 



After-treatment. — The dressing should be inspected every one or 
two days for the first week, and every third day during the second 
week. If the radiogram shows that reduction is faulty, further re- 
duction should be accomplished. At every dressing the splint should 
be removed, the arm bathed, and moderate massage and passive 
motion of the wrist-joint performed by the surgeon. At the end of 
the second week the posterior splint may be discarded if two splints 
have been employed. At the end of three or four weeks all may be 
removed. An adhesive plaster cuff two inches wide may be used for 



414 TREATISE ON FRACTURES 

slight protection for a week or two longer. Some patients who are 
careful or are not exposed to strain upon the forearm and hand will 
not require such a long period of restraint. Some cases will need very 
little dressing, except an adhesive plaster cuff, from the beginning. 

The more or less transverse fracture about a half inch above the 
radiocarpal joint, with displacement of the lower fragment forwards, 
is often called Smith's fracture, or reversed Colles's fracture. It 
produces a deformity resembling the planes of a gardener's spade in- 
stead of the silver-fork deformity of the typical transverse fracture 
in the same portion of the radial base. 

Its treatment should be conducted on the same principles as the 
typical or so-called classic fracture, which is similar in etiology except 
that the force in that instance drives the lower or basal fragment 
backwards. Forcible reduction, under anaesthesia if need be, to re- 
construct the normal arch of the palmar surface of the radius is 
demanded. Then a moulded gypsum splint to maintain the integrity 
of this arch or a metal splint similarly fitting the anatomical contour 
should be applied, permitting free motion of the fingers. Frequent 
removal of the retentive dressing, with light massage and mobilization, 
will complete the cure in about three or four weeks. 

The classic fracture is very common, is often mistaken for a strain, 
is very frequently badly treated, because not reduced, and therefore 
causes patients and physicians much trouble. It is easily treated if 
promptly reduced and kept reduced. The dressing should be simple 
and f requently removed for inspection during the first ten days. Then 
it may be replaced by a gypsum encasement, split or not split. 

Surgeons see every year cases that have not been reduced. Refrac- 
ture should then be performed if the injury is less than three months old. 
After that osteotomy is probably better. The incision should be made 
on the radial edge of the wrist. Sometimes there is great radial devia- 
tion from imperfect reduction of the fragments or crushing or impac- 
tion of bone ; sometimes the ulna may cause a prominence at the back 
of the wrist. The ulna may be shortened by removing a disk with 
the Gigli wire saw, if the radial displacement of the hand is great from 
shortness of the radius. If deformity arises from unreduced anterior 
displacement of the carpal fragment, osteotomy will be a means of 
relief as it is in unreduced posterior displacement 

After-results. — It is a remarkable fact that many bad anatomical 
results are finally followed by fairly good functional results. Bad 
functional results are in most instances due to incomplete reduction of 
fragments. In a small number of cases, however, poor functional 
results are due to a perineuritis, limitation of motion due to a coin- 
cident tenosynovitis followed by adhesions and circulatory disturb- 
ances. Many of these poor results will be obviated by passive motion 



FRACTURES OF THE RADIUS AND ULNA 415 

and massage from the day of fracture. This is especially so in people 
of advanced years. In these cases the part should not be allowed to 
stiffen. This can be prevented by daily massage and passive motion. 
Bad results nearly always mean failure to reduce fragments, or incom- 
plete reduction and prolonged immobilization. Both factors may be 
the cause of the bad result. 

In cases in which deformity persists, it is generally due to failure 
of reduction, and consists in posterior displacement with rotation and 
abduction of the lower fragment; the ulnar styloid is prominent, the 
radius shortened, and the wrist broadened. Fractures of the lower end 
of the radius have a reputation of being difficult to treat with favorable 
results. This opinion is due to the long-standing unwillingness of 
many members of the profession to admit that complete reduction im- 
mediately after the receipt of injury is the keynote to success. Early 
complete reduction, early superficial massage, and early mobilization, 
active and passive, will give a satisfactory functional result in the vast 
majority of fractures of the base of the radius. These fractures are 
especially satisfactory for treatment if the surgeon appreciates these 
necessary factors in the management of the lesion. They prove the 
doctrine of Lucas-Championniere to be of high significance in fracture 
treatment. 

Summary of Treatment of Fractures of Radius and Ulna 
reduction first 

Fractures of Radius and Ulna Combined. — Upper Two-thirds of 
Shafts. — Flexed elbow, supination, anterior angular support with 
gypsum contour splint, wood or metal angular splint. Sometimes 
additional posterior splint. Gypsum encasement after swelling, but 
must be split to give frequent inspection. Look out that round pro- 
nator does not pronate upper fragment of radius. 

Lowest Third of Shafts. — The same as above; immobilization 
of elbow not always necessary in lowest third, but use an anterior and 
a posterior splint. Operation if reduction is not maintained, direct 
fixation. 

Fractures of Ulna (Isolated). — Olecranon, extended elbow with 
anterior straight splint or gypsum-gauze contour splint. Operation 
occasionally. 

Coronoid process, hyperflexion of elbow. Operation of excision 
sometimes needed. 

Shaft. — Upper two-thirds, flexed elbow, supination, anterior right 
angle splint or gypsum-gauze contour splint. 

Lowest one-third, flexed elbow, supination, an anterior and a pos- 
terior splint ; or, if no displacement, anterior splint of gypsum, wood or 
metal only, from elbow to mid-metacarpal region. 



410 TREATISE ON FRACTURES 

Fractures of the Radius (Isolated). — Head. — Flexed elbow; supi- 
nation, with anterior right angular splint; or pronation with internal 
angular splint. Operation for excision of head occasionally. 

Neck. — Flexed elbow, anterior right angle splint, operation for 
excision of fragment occasionally. 

Shaft. — Upper one- third flexed elbow, supination, right angle an- 
terior splint or gypsum contour. Middle and lower one-third flexed 
elbow, mid-pronation, anterior and posterior splints from elbow to 
metacarpal heads. Operation for direct fixation with moderate fre- 
quency. 

Uower End or Base of Radius. — Be sure to break up impaction, 
and reduce with great force, if necessary, to restore arch of anterior 
surface of radius. Maintain with wrist flexed, in usual fracture, by 
anterior trough, or posterior contour of gypsum-gauze; or, if do not 
flex wrist, employ posterior straight splint or anterior and posterior 
straight splints with firm pad under arched lower fifth of anterior sur- 
face of bone. 

Old unreduced fracture, refracture, or reconstruct bone by 
osteotomy. 



CHAPTER XVII 

FRACTURES OF THE CARPAL BOXES 

Anatomy. — The eight bones forming the carpus (Fig. 520) are 
arranged in two rows, the proximal and the distal. Enumerated from 
the radial to the ulnar side the proximal row are : scaphoid, semilunar, 



Flexor carpi radialis 



Styloid process ^o^, 

Scaphoid 
Tuberosity o£ scaphoid 

Trapezium 

Ridge on trapezium 

Trapezoid 

Flexor carpi radialis "1 



Ulna 
9Hh& Flexor carpi ulnaris 




Styloid 
Semilunar 
Cuneiform 
Pisiform 
Os magnum 
Unciform 
Unciform process 
Flexor carpi ulnaris 



Fig. 520. — Anterior view of the bones of the carpus and the metacarpus 



cuneiform and pisiform; the distal row are: trapezium, trapezoid, os 
magnum, and unciform. 

The lower end of the radius and the lower surface of the triangular 
fibrocartilage articulate with the upper surfaces of the scaphoid, semi- 
lunar, and cuneiform bones. The ulna is separated from the articula- 
tion by the triangular fibrocartilage; the pisiform bone does not enter 
into the articulation. The lower row of carpal bones articulates with 
27 417 



418 TREATISE ON FRACTURES 

the metacarpals as follows : the trapezium with the first metacarpal, 
better called the proximal phalanx of the thumb: the trapezoid with 
the second metacarpal : the os magnum with the third metacarpal : and 
the unciform with the fourth and fifth metacarpals. The carpal bones 
are irregularly shaped and take their names from objects which they 
resemble. 

The carpal ligaments join the bones of the forearm, the carpal and 
metacarpal bones, together and consist of the radiolateral ligament, the 
ulnar lateral ligament, the anterior radiocarpal ligament, the posterior 
radiocarpal ligament, and the transverse carpal or anterior annular 
ligament. In addition there are ligaments which tmite the carpal to 
the metacarpal bones, and are known as the volar and dorsal inter- 
carpal, the volar and dorsal carpometacarpal ligaments, and the volar 
and dorsal basal ligaments. 

Surface Markings. — The site of the radiocarpal joint is the space 
between the styloid process of the radius and the tubercle of the 
scaphoid and its line is convex proximally. The line of the intercarpal 
joint corresponds to the lowest transverse furrow in front of the wrist; 
this also marks the upper edge of the anterior annular ligament. On 
the flexor surface of the wrist the tubercle of the scaphoid may be felt 
below the styloid process of the radius, the trapezium below the tubercle 
of the scaphoid, the pisiform below the ulnar styloid, and the cunei- 
form to the inner side of the pisiform. 

Statistics. — Plagemann's statistics from Midler's surgical clinic at 
Rostock, based upon radiographic diagnosis of 1393 fractures, shows 
the carpal bones to be involved in 29 instances ( 2.0S per cent.), divided 
as follows : 

Fractures vi the scaphoid 13 0.93 

Fractures of the semilunar 5 0.359 

Fractures of the cuneiform 3 0.21 

Fractures of the os magnum 1 0.07 

Fractures of the scaphoid and semilunar 5 0.509 

Fractures of the scaphoid, semilunar and cuneiform 1 0.07 

Etiology. — Fractures of the carpal bones may be the result of 
direct violence, as a blow from a heavy instrument, or of indirect 
violence, as a fall ujxrn the hand either in flexion <>r extension, and at 
times with the hand in rotation or abduction. They most frequently 
result fr<>m such forces as usually produce fracture of the base of the 
radius, viz.. a fall upon the extended or hyperflexed pronated hand. 
They are occasionally seen in combination with fracture of the bones 
of the forearm, usually a fracture of the styloid of the radius or a 
comminuted fracture of the lower end of the radius. Carpal fracture 
may occur in conjunction with a dislocation of other carpal lx>nes. The 
variation in frequency is well shown in Plagemann's sta: is 



FRACTURES OF THE CARPAL BONES 



419 



Symptoms. — Those common to fractures of any of the carpal bones 
are localized pain, tenderness on pressure, and local swelling, and pain 
on movement of the wrist-joint, particularly on abduction or adduc- 
tion. Many of these cases go unrecognized for weeks and are errone- 
ously treated as sprains of the wrist-joint. At times there is a history 
of injury, followed by severe pain, swelling and tenderness, with pain 
on motion, which after a few days subsides to a certain degree but 
fails to entirely disappear. There is inability of full passive flexion or 
expansion of the wrist-joint, which is accompanied by muscular spasm. 
There is generally no crepitus or ecchymosis present. Swelling per- 
sists, and the outline of the extensor tendons of the thumb is more or 




1 










* "•■'. 


' 




11 








1 






] 



Fig. 521. — Comminuted fracture of the carpal scaphoid. 
Fig. 522. — Fracture of the carpal scaphoid. 

less obliterated by this persistent swelling, particularly in fractures of 
the scaphoid. 

In fractures of the scaphoid (Figs. 521-525) there is limitation of 
extension, local pain in the hollow between the extensors of the pha- 
langes of the thumb, when the hand is in the adducted position. The 
lesion is generally a fracture at the neck of the scaphoid, without 
much displacement of fragments. When displacement of fragments 
occurs, it is generally the proximal fragment that is dislocated. Flexion 
of the wrist shows abnormal prominence formed by the scaphoid, 
anteroposterior thickening, and definite pain and tenderness over the 
scaphoid in the region of the anatomic snuff-box and at times pos- 
teriorly. In old cases there will be found definite swelling over the 



420 



TREATISE ON FRACTURES 

'ig. 523. Fig. 524. 




Figs. 523 and 524. — Sprain-fracture of the tubercle of carpal scaphoid. 




Fig. 525. — Fracture of the carpal scaphoid with backward luxation of the radial fragment, which was 

removed at operation. 

Fig. 526. — Fracture of carpal semilunar, direct violence. 

radial half of the wrist-joint. In all cases anteroposterior and lateral 
radiograms should be made, so that a definite diagnosis may be made 
and the presence of comminution or displacement of fragments noted. 
It should be remembered that occasionally supernumerary carpal bones 



FRACTURES OF THE CARPAL BONES 421 

or additional centres of ossification may be mistaken for fractures of 
carpal bones, when X-ray examinations are made. 

Fractures of the semilunar are usually the result of great direct 
violence, gunshot and open wounds, and are generally associated with 
other injuries. Fracture of the semilunar (Fig. 526) shows local 
pain, tenderness on pressure, and pain on motion, particularly on forced 
extension. Swelling is marked over the region of the bone rather 
than being limited to the radial side, as in scaphoid fractures. 

Fractures of the cuneiform are extremely rare. They are the result 
of direct violence. The same may be said of the remaining carpal 
bones. The usual symptoms would be local pain, tenderness on pres- 
sure, and passive motion with local swelling. 

Diagnosis. — Injuries of the wrist-joint should be carefully studied 
clinically, and by radiography, always in two planes, when suspicious 
symptoms persist for more than a day or two and diagnosis is difficult. 
Actual fracture usually will show that active and passive movements at 
the wrist-joint are limited and painful ; and attempts to continue pas- 
sive motion beyond a certain degree probably will be followed by ex- 
treme pain and at times muscular spasm. Crepitus and ecchymosis are 
rarely observed, while swelling is persistent. When these symptoms 
last for a considerable length of time a diagnosis of carpal fracture 
may with propriety be made, and can often be confirmed by radiogram. 

Treatment. — The line of treatment to be adopted in the individual 
case depends upon the time which has elapsed since the receipt of the 
injury, and the occurrence or absence of displacement of fragments. 
When dislocation of a fragment or fragments is present, which cannot 
be overcome by manipulation, excision of one or several fragments 
should be performed. When there is no displacement of fragments 
and the patient is seen shortly after injur3 r , attempts to secure union 
should be made during from four to six weeks. This is to be under- 
taken by placing the hand and forearm at rest upon a well-padded 
anterior splint of wood, reaching from the bend of the elbow to the 
tip of the fingers, with the hand in semi-pronation. Instead of this 
dressing a well-fitting plaster-of-Paris case, which is better, may be 
used. If union has not resulted in four to six weeks, as shown by the 
radiogram, excision of one or both fragments should be performed. 
Whenever symptoms of discomfort or disability persist after excision, 
the parts should be immobilized for a period of two weeks, when 
active and passive motion should be begun. Supernumerary bones 
or unusual ossific centres should be differentiated from the supposed 
fracture before operation is performed for removal of a suspected 
fragment. Gouty or tuberculous disease might be the cause of the 
carpal pain and swelling. A slipping fragment may be held in place 
until union occurs by boring a small hole with a brad-awl and nailing 
it in position with a steel needle or a small wire nail. 



CHAPTER XVIII 

FRACTURES OF THE METACARPAL BONES 

Anatomy. — The metacarpal bones (Fig. 520), five in number, sup- 
port the fingers and form the skeleton of the palm of the hand. They 
are long bones and may be divided into a base, shaft, and distal end or 
head. The bases articulate with the carpal bones and the heads articu- 
late with the proximal phalanges. 

The metacarpophalangeal articulations are characterized by the 
fact that, while the articular surfaces are irregularly spherical, the 
range of motion is limited by the strong lateral ligaments, so attached 




Fir.. 527-— Transverse fracture of first, metacarpal at the junction of the base and the shaft. 
Fig. 528. — Oblique fracture of the shaft of the first metacarpal. 

to the heads of the metacarpal bones that they become tense on flexion 
of the phalanges. The capsules of the joints are also reinforced by 
the accessory volar and the transverse capsular ligaments. 

Surface Markings. — The metacarpal bones can be readily palpated 
throughout. The heads of the metacarpal bones form the first row 
of the knuckles. 

Statistics. — Plagemann's statistics from Midler's clinic at Rostock- 
shows that of T393 fractures radiographically diagnosed there were 46 
metacarpal fractures, divided as follows: first metacarpal, 9 times; 
second, 16 times; third, (; times; fourth, 4 times; and fifth, 8 times. 
422 



424 



TREATISE ON FRACTURES 



His statistics also show that the case and the head are less frequently 
fractured than the shaft, with the exception of the first metacarpal. 



t&l 





Fig. 534. Pto. 535- 

• m 

in about 
Fig. 5J5. — Tracsver- 

and here there ,vere in 9 cases 6 fractures of the base. In addition to 
the usual oblique and transverse fractures of the bodies of the meta- 




426 



TREATISE ON FRACTURES 



carpals, there were in nine instances spiral fractures of the hodies. 
and in one instance he observed an epiphyseal separation of the head 
of the fourth metacarpal with an attached portion of the diaphysis. 

Etiology. — Fracture of the metacarpals may be the result of either 
indirect or direct violence. Those by indirect violence are generally 
due to force applied upon the distal end of the bone in its long axis, 
such as occurs in the striking of a blow or in a fall upon the flexed 
hand. The normal arch of the bone is exaggerated, and fracture 
occurs. Fractures by direct violence are usually the result of a severe 
blow or crushing force on the back of the hand. Fractures are usually 
transverse or oblique, though occasionally spiral, fissured, or com- 
minuted. The spiral fracture is most frequently observed involving 




FlG. 530. — Method of determining crepitus and mobility of fragments in fracture of the metacarpals. 

the fourth or fifth metacarpals. Here a twisting force, such as a fall 
upon the back of the hand or the fingers, produces the fracture. 

Symptoms. — Fractures of the first metacarpal or, better called the 
first phalanx of the thumb, differ from those of the other four meta- 
carpals to such an extent that they should be considered separately. 
Fractures of the shaft of this bone give the usual symptoms of .frac- 
ture; these fractures are rare. The usual fracture of the first meta- 
carpal involves the base of the bone, and here three varieties of frac- 
ture occur. The first variety I Figs. 527 and 528 ) is a transverse or 
irregular oblique fracture at the junction of the shaft and base not 
involving the articular surface, and is generally impacted. The second 
variety | Figs. 529 53] | is the oblique fracture, the fracture line run- 
ning upward and backward through the base of the metacarpal, the 



FRACTURES OF THE METACARPAL BONES 427 

Fie. 540. 



( 






, 




Fig. st 




Figs. 540, 541 



so-called " stave of the thumb " or Bennett's fracture. The upper 
end of the lower fragment in this injury is displaced upward and 



428 



TREATISE ON FRACTURES 



backward, and resembles a subluxation of the metacarpal plus crepitus. 
This fracture is always observed in adults. -The third variety (Figs. 
532 and 533) of fracture is an epiphyseal separation of the basal epi- 
physis with a fracture through a small portion of the diaphysis. The 
symptoms of all of these fractures are deformity, crepitus when im- 
paction is absent, shortening of the thumb, and pain and tenderness 
on pressure. 





\:\ 



Figs. 543. S44. and S4 






vood splint for fractures of 



Fractures of the other four metacarpal bones (Figs. 534-538) are 
readily recognized by deformity, localized pain and tenderness on 
pressure, at times crepitus, shortening of the affected bone, and irregu- 
larity of the knuckle's outline in the hand affected. An infallible sign 
of fracture is pain at the seat of fracture on making direct firm pres- 
sure over the knuckle in the longitudinal axis of the bone (Fig. 539). 
J 'ain will often be elicited by the surgeon making traction on the finger 
and then pushing the bones of the finger toward the wrist. 



FRACTURES OF THE METACARPAL BONES 



429 



Diagnosis. — In doubtful fractures, particularly those at the base of 
the second, third, and fourth metacarpals, radiograms should be made 
to establish the diagnosis. 

Treatment. — Impacted fractures of the base of the first metacarpal 
should be immobilized on a gutter splint of aluminum, or a moulded 






i-IGS. S46, 547, and s48.-Method of application of padded palmar splint for fracture of the second to 
fifth metacarpals, when a tendency to recurrence of deformity is not present. 

gyp?-m splint, for three or four weeks; the impaction need not be 
interfered with unless deformity is great. In the other fractures of 
the first metacarpal, reduction should be made and maintained by the 
use of a gutter splint for three to four weeks (Figs. 540-542) . Frac- 



430 TREATISE ON FRACTURES 

tures of th£ other four metacarpals should be treated by reduction, 
consisting of traction and manipulation, and the corrected position 
maintained by a well-padded posterior splint of wood, extending from 
the upper third of the forearm to the tip of the fingers (Figs. 543- 
545). Immobilization should be maintained for three to four weeks. 
It is frequently difficult to maintain proper apposition in oblique frac- 
tures of the shaft. 'When no deformity is present a palmar tin splint 
may be used (Figs. 546-548). 

In fractures of the shafts of the last four metacarpals, recurrent 
angular deformity may be overcome by the use of the roller bandage 
placed in the palm of the hand with the fingers flexed over it and held 
in place by suitable dressing and a bandage. In some instances a hard 
ball of rubber or ivory or celluloid placed in the palm will probably 
answer the purpose better. When over-riding of fragments persists, 
permanent traction and counter-traction may be used. Satisfactory 
traction is readily made by fastening lateral strips of adhesive plaster 
to the finger and tying their distal ends over a tack driven into the end 
of a palmar splint of wood fixed to the forearm and extending beyond 
the finger-tips. To secure counter-traction the board should be cut 
narrow just above the thenar eminence, and be fixed to the wrist by 
a wristlet of adhesive plaster. The ends of the traction strap may be 
secured to the tack by a rubber cord. Another good method is to 
reduce the fracture and nail its f ragments together with a brad-awl and 
a straight surgical needle or a carpet tack. 

After-results. — The great majority of fractures of the metacarpals 
are followed by good functional results, even in the presence of mod- 
erate deformity. Epiphyseal separation of the metacarpals may be 
followed in later life by failure of development of the metacarpal and 
subsequent shortening with deformity, 



CHAPTER XIX 

FRACTURES OF THE PHALANGES 

Anatomy. — There are three bones or phalanges to each of the 
fingers, and two to the thumb. They may be divided into the proximal 
or first row, the middle or second row, and the distal or third row. 
Like all long bones they may be divided into two extremities and a 
shaft. The interphalangeal articulations are formed by the bases form- 
ing the articular sockets, and the trochlear surfaces forming the articu- 
lar heads. They are held together by lateral ligaments. 

The lines of the interphalangeal joints may be determined by the 
position of the transverse furrows on the palmar surface of the fingers. 
The first furrow is midway between the metacarpophalangeal articula- 
tion and the joint between the first and second phalanx; the two 
remaining furrows represent the position of the interphalangeal joints. 
The distal ends of the first phalanges form the second, and the distal 
ends of the second phalanges form the third row of knuckles. 

Statistics. — Plagemann's statistics from the Rostock clinic, based 
upon the radiographic examination of 1393 fractures, shows 75 (5.405 
per cent.) fractures of the phalanges. Of these 42 were complicated 
and 33 subcutaneous fractures. Of the 75 only 59 were subsequently 
radiographically examined, and of these there were 19 fractures of 
the first phalanx, 19 of the second phalanx, and 25 of the distal 
phalanx. In the fractures of the distal phalanx 10 were comminuted. 
The most frequent were fractures of the index-finger, then the fifth 
finger, the third finger, the thumb, and the fourth finger. 

Etiology. — Fractures of the phalanges (Figs. 549-553) are usually 
caused by direct violence, such as blows and machinery accidents, but 
occasionally are the result of indirect violence, such as a fall upon the 
tip of the extended finger or a blow as in catching a baseball. Frac- 
tures by direct violence may involve any portion of the bone, while those 
produced by indirect violence are more commonly noted as involving 
the base of the phalanges. Many of the fractures of the phalanges are 
compound, which is due usually to the nature of the injury and the sub- 
cutaneous character of the bones. Fracture of the phalanges may be 
fissured, multiple, comminuted, oblique, transverse and articular. 

Symptoms. — The symptoms of fracture of the phalanges are local- 
ized pain, swelling, tenderness on pressure, deformity, abnormal mo- 
bility, crepitus, and widening at the seat of fracture with slight dis- 
placement. As many of these fractures are open, there is in addition 
direct evidence of the presence of the fracture. 

431 



432 



TREATISE ON FRACTURES 



Fig. 549- 




Fig. 549. — Transverse fracture of proximal phalanx of thumb. 
Fig. 550. — Comminuted fracture of proximal phalanx of fifth finger. 




FRACTURES OF THE PHALANGES 



433 



Diagnosis.— Diagnosis of 
fracture of the phalanges 
can, as a rule, be readily 
made, even without the radio- 
gram. Difficulty will at 
times be experienced in diag- 
nosing articular fractures ; 
here the use of the radiogram 
will materially help in diag- 
nosis. However, in its ab- 
sence a diagnosis may be 
made by widening of the 
.bone, deformity, preter-nat- 
ural mobility, and the ten- 
dency toward displacement 
which is present. 

Treatment. — In the treat- 
ment of phalangeal fractures, 
reduction is generally accom- 
plished by traction and main- 
tained by the use of a padded 
wood or tin or aluminum 
splint (Figs. 554-559) ap- 
plied to the flexor surface of 
the palm of the hand and fin- 
gers and held in place by ad- 
hesive plaster and bandage. 
Gypsum encasements wi 
often be better than wooden 
splints. In some cases de- 
formity may be prevented by 
splinting the injured and the 
next finger together. In 
some fractures in which de- 
formity is recurrent, it may 
be prevented by the use of a 
traction apparatus. 

In open fractures the 
wound should be thoroughly 
sterilized with iodine or other 
antiseptic and closed, and 
then treated as a simple frac- 
ture. Necrosis of bone may 
28 




Figs. 554. S55, and 556.— Method of application of padded 
splint for fractures of phalanges of index finger. 



434 



TREATISE ON FRACTURES 



follow in some cases and the 
final result may be healing 
with loss of bony structure. 
Open and comminuted frac- 
tures should not be subjected 
to hasty amputation, because 
fingers may often be saved by 
plastic procedures. Denuded 
bones ma}' be covered with 
tegumentary flaps from other 
fingers or parts of the hand. 
In some cases the stripped 
bones may be inserted into a 
space or pocket, made by an 
incision or incisions in the 
skin and superficial fascia of 
the patient's abdomen or 
thigh, and thus provided with 
cutaneous covering. In other 
instances free flaps may be 
transplanted to the hand and 
the denuded phalangeals may 
be subsequently modelled into 
useful fingers. These pro- 
cedures are particularly valu- 
able when the thumb is in- 
jured, for its opposing press- 
ure against another part of 
the hand or even a stump of 
a finger gives the patient a 

inum splint for fractures of phalanges of" fingers. crraSD 

After-results. — Union occurs in closed fracture in three to four 
weeks. In articular fractures union may occur with ankylosis of the 
opposing joint surfaces. In open fracture healing may follow only 
after necrosis and loss of bonv structure. 





CHAPTER XX 

FRACTURES OF THE PELVIS 

Anatomy. — The pelvis (Figs. 560 and 561) is formed by the two 
innominate bones, the sacrum and the coccyx. The innominate bone 
in the adult consists of a single bone, formed by fusion of its three 
constituents — the ilium, ischium, and pubes. In childhood it consists 
of these three bones separated by a Y-shaped cartilage on the floor of 
the acetabulum. This ossifies and unites the segments about the four- 
teenth or fifteenth year of life. The innominate bone is irregular in 
form, shaped like the blade of a screw propeller. It is narrow near its 
centre where the acetabulum or socket for the head of the femur 
exists, and expanded above and below this region. The ilium is the 
largest of the three segments, forms about the upper third of the 
acetabulum, and consists of an expanded portion called the ala, and 
the body. The ischium is 'composed of a body and two rami, the 
superior and the inferior, which form the posterior and inferior boun- 
dary of the obturator foramen. Its body forms approximately the 
inferior two-fifths of the acetabulum, and terminates at its postero- 
inferior part in the tuberosity of the ischium. The pubic bone has a 
horizontal and a descending ramus and forms the anterior inferior 
portion of the innominate bone. It consists of a body articulating in 
the median line of the human trunk with the body of the opposite 
pubic bone and the two branches or rami mentioned above. The body 
forms the anterior part of the acetabulum, and the superior and infe- 
rior rami form the antero-inf erior boundary of the obturator foramen. 
Where the os pubis joins that of the opposite side anteriorly, there is 
fibrocartilage forming part of the synchondrosis; this generally be- 
comes ossified at puberty. The inferior ramus is separated from the 
inferior ramus of the ischium by cartilage which becomes ossified 
about puberty. Together these two rami form the lower border of 
the obturator foramen. 

The ligaments of the pelvis are the following: pubic articulation, 
superior pubic ligament, inferior pubic ligament, anterior pubic, pos- 
terior pubic, and subpubic, and the interposed fibrocartilage ; sacro-iliac 
articulation, the anterior sacro-iliac ligaments, the short posterior sacro- 
iliac ligaments, the long posterior sacro-iliac ligaments ; the connection 
of sacrum with ischium is by the great or posterior sacrosciatic liga- 
ment, the small or anterior sacrosciatic ligament, and the interosseous 
sacrosciatic ligament. The ilium is joined to the fifth lumbar vertebra 
by the iliolumbar ligaments. 

435 



436 TREATISE ON FRACTURES 

Surface Markings. — The ala of the iliac bone may be palpated 
laterally as well as the spine of the pubes anteriorly. Posteriorly may 
be felt the posterior superior iliac spines, which are on a level with the 
middle of the sacro-iliac joint, the two tubercles of the last sacral 
vertebra, the base and tip of coccyx, and the tuberosities of the ischia. 

The bladder occupies the anterior part of the pelvis, situated be- 
tween the pubic bones and the rectum in the male and between the 
pubic bones and the uterus and vagina in the female. In extraperi- 
toneal rupture of the bladder extravasation of urine is limited by the 
reflection of peritoneum known as the posterior false and lateral false 
ligaments of the bladder. 

Statistics. — Plagemann's statistics from Muller's clinic at Rostock, 
based upon the rontgenographic diagnosis of 1393 fractures, shows 



Posterior superior spine 

Posterior border 

Posterior inferior spine 

Great sacrosciatic notch 

Body of 



Spine of ischium 

Obturator foramen 

Tuberosity 



Midde gluteal line 
Anterior superior spine 




Articular surface 
Acetabulum 

Non;:rticular surface 



e bone, outer aspect. (Piersol.) 



17 cases (1.22 per cent.) of fracture of the pelvis, divided as follows: 
pelvic girdle fractures, 6 cases; acetabulum fractures, 5 cases; isolated 
fractures of the pubes, 3 cases; and isolated fractures of the ilium, 3 
cases. J. Jensen collected the records of four Copenhagen hospitals 
for five years, and found 80 cases of fracture of the pubes, shown by 
rontgenoscopy, operation, or necropsy. Of this number the 25 fatal 
cases showed that the trauma had more serious consequences at other 
points, excepting in three cases, in which the patients died as a result 
of complications of the fracture, and one, a child, who died as a direct 
result of the accident. In 6 cases the pubes alone was fractured and 
in 2 cases there were isolated fractures of the sacrum and ilium. In 
55 clinical cases there was isolated fracture of the pubes in 22 in- 
stances, and pubic fracture associated with fracture of the ischium in 



FRACTURES OF THE PELVIS 



437 



7 instances ; isolated fracture of the acetabulum in 5 instances ; isolated 
fractures of the ilium in 9 instances; and in 2 cases either the sacrum 
or the ischium alone was fractured. In 2 there was a double vertical 
fracture, in 6 fracture and dislocation, and in 2 dislocation alone. In 
21 cases there were complications of the urinary system, including 5 
with a fatal result. There was urinary retention in 16 cases, but in 
5 cases of this group the urine was normal ; dysuria in 2 cases ; the 
urethra was ruptured in 3 cases, and the bladder in 3 cases — the latter 
all proved fatal. 

Fractures of the pelvis, as a rule, require a great degree of violence 
for their production, although there are reported cases in which the 
fracturing force was slight. Pelvic fractures may be the result of 
direct or indirect violence, and rarely of muscular* action. Falling 



Crest of ilium 



Ilium 

Promontory of 

sacrum 

Anterior superior 

spine 

Inferior superior 

spine 

Iliopectineal line 

Body of pubis 

Spine of ilium 

Acetabulum 

Spine of tubis 

Symphysis 




Spinous process 
Articular process 
Body of sacrum 

Transverse process 



Oburator foramen 



Fig. 561. — Male pelvis, anterior view. 

embankments or elevator cars, the passage of vehicles across the 
pelvis, crushing force such as being caught between the bumpers of 
cars, blows, falls from a height, and very rarely sudden muscular 
strain, are the kinds of injuries which generally produce fracture of 
the pelvis. Transmitted force, such as falls upon the feet or trochanter, 
may produce these lesions. The fracture lines are usually multiple, 
rarely compound, and are dangerous to life on account of the damage 
to the pelvic contents which may result in conjunction with the 
fracture. 

The character of fracture depends upon the direction of the frac- 
turing force, and is usually limited to certain definite areas, except when 
the fracturing force is an extreme form of crushing. Fractures occur 
where the thin portions of the bone unite with the thicker portions, or 
where the pubic, iliac, and ischiatic elements of the bone before adult 
life are united by cartilage. The pelvis, as shown by Katzenelson, con- 



438 



TREATISE ON FRACTURES 





FRACTURES OF THE PELVIS 



439 



sists of two semicircles, each formed of an anterior and posterior arm, 
with the acetabulum as the summit. In the anterior arm the line of 
fracture occurs at the tuberosity of the pubes, the iliopectineal line, 
the ascending ramus of the ischium, and at the junction of the ascend- 
ing ramus of the ischium with the descending ramus of the pubes. In 
the posterior arm the fracture line passes vertically from the pelvic 




Fig. 564.— Fracture of the pelvis. The anterior 
rami of the pubis, and the posterior line passes veri 
close to the sacro-iliac synchrondrosis; the so-called ' 



lines of fracture involve the body and descending 
ically through the ilium behind the acetabulum 
double vertical fracture" of Malgaigne. 



bone down through the greater sciatic notch of the ilium, through the 
lateral masses of the sacrum, irregularly diagonal through a portion 
of the ilium and sacrum, and through the sacro-iliac synchondrosis. 
Varieties.— Fractures of the pelvis may be classified: 
Fractures of the rami of the pubes (Figs. 562 and 563) occur 
from direct violence directed from in front either posteriorly or 



440 



TREATISE ON FRACTURES 



laterally and are the most common form of fracture. The line of 
fracture passes, as a rule, through the superior ramus of the pubes 
anterior to the iliopectineal eminence and through the inferior ramus 
of the pubes. At times the latter line is very oblique and passes 
through the inferior ramus of the ischium. There may or may not be 
an accompanying separation of the sacro-iliac synchondrosis. Dis- 
placement of the fragments may he marked. 

Fracture of the Rami with Fracture of the Posterior Arm 
of the Pelvic Arch (Figs. 564 and 565).— In this fracture the 



jm 


M 




w0 


K 


V|j 




w 


^ 


u. 


¥ 






1 


1^.T 


, 


* 


_.' 


s^pr 


«.* 







Fig. 565.— Pelvis with fourth and fifth lumbar 
ramus of the pubes, of the ramus of the ischium, 1 
fourth body of the sacrum. (Mutter Museum, i.j8 



vertebrae. Fracture of the symphysis, body and 
ith the sacro-iliac separation and fracture of the 



anterior fracture line passes through the superior ramus of the pubes 
or the ramus of the ischium, and the posterior part of the fracture line 
passes vertically through the ilium behind the acetabulum, or through 
the sacrum, or partially through the ilium, the sacrum, and the sacro- 
iliac synchondrosis. It has been called the double vertical fracture of 
Malgaigne. The injury occurs from anteroposterior or lateral crush- 
ing. Marked displacement of the middle fragment often results. This 
fragment, consisting of the acetabulum with the attached head of the 
femur, is generally displaced upward with the leg; and it may rotate 



FRACTURES OF THE PELVIS 



441 



around a vertical or horizontal axis, so that the shape of the pelvis is 
altered and the extremity of the involved side apparently shortened. 

Separation of the symphysis pubis (Fig. 566) occurs between 
one of the pubic bones and its attached cartilage, rather than between 
the two cartilages which belong to the joint. This separation may be 
the result of parturition, forced abduction of the thighs, or by direct 
external violence. The gap between the two bones may be several 
inches in width ; occasionally the fracture is an open one. 

Separation of the sacro-iliac synchondrosis (Fig. 567) is 
extremely rare. Cases have been reported by Malgaigne and by Stim- 




Fig. 566. — Fracture of the pelvis 
pubis 



vis. llic line ui udtiuit invuiveb me uuuy an 

th separation of the synchrondrosis of the latter 



nvolves the body and the symphysis of the 



son. It is truly a dislocation. Much has recently been written on 
partial luxation here being frequent and causing painful backs. 
Dr. Goldthwaite, of Boston, has given this injury great attention. 

Separation of the symphysis pubis and the sacro-iliac syn- 
chondrosis has been observed by Malgaigne, Earle, Creite and Sal- 
leron. In the reported cases the injury occurred through a fall from 
a height upon one foot, or from the pressure of a heavy weight upon 
the pelvis. Displacement consisted in elevation of the affected half of 
the pelvis. 

Separation of the symphysis pubis and of both sacro-iliac 
synchondroses is extremely rare. The few reported cases were 




Fig. 5:" — I 2 Esactoure . . * first --I second sacral 

■ - ! - rtfshed and the body of the pctbes and ramus of the ischium are fractured. (Mutter 
! - K - 




i : head of the right 
The greater trochanter 
13 in etc I - 



FRACTURES OF THE PELVIS 



443 



accompanied by multiple fractures of the pelvis and were the result of 
extreme violence. 

Fractures of the acetabulum (Figs. 568-575) may occur as a 
radiating- fracture in the direction of the conjugal Y-cartilage seen in 




Figs. 569, 570 and 571. — Photographs of case of fracture of the floor of the acetabulum with 
central dislocation of the head of the femur. See Fig. 568. Lateral view shows absence of normal 
prominence of greater trochanter; anterior view shows tilting of pelvis with shortening of the distance 
between the anterior superior spine of the ileum and the greater trochanter, and the posterior view 
shows spinal curvature and flattening of gluteal crease on the right side. 

adolescence, in which the fracture line runs into the sciatic notch, 
the obturator foramen, and over the brim of the pelvis. Other forms 
of fracture are those associated with fracture through the rami of 
the pubes and are irregular in character, those involving the rim 
of the acetabulum in association with partial dislocation of the head of 



444 



TREATISE ON FRACTURES 



femur, and those in which there is fracture of the acetabulum with in- 
complete or complete penetration of the head of the femur through it 
into the pelvic cavity, the so-called central luxation of the femur. 
These fractures are usually the result of great violence applied directly 
over the side of the pelvis and great trochanter or over the external 
and upper surface of the thigh with the thigh in the position of marked 
abduction. 




of the pelvis. An incomplete form of the 
The line of fracture involves the floor of tr 



so-called "central dislocation of 



FlG. 572. — Fractu 
the head of the femur.' 
norly into the great 

Isolated fractures of the sacrum are rare and the lesion most 
frequently reported is a more or less transverse fracture below the 
sacro-iliac synchondrosis with displacement of the lower fragment 
into the pelvis. This fracture results from great direct violence applied 
from behind or from a fall upon the sacrum. 

Isolated fractures of the ilium (Figs. 576-579) may consist 
of a fracture of the expanded portion close to the linea arcuata, in 
which the line is irregular and more or less transverse, the so-called 
Duverney fracture, or a fracture of the epiphysis of the crest. Com- 



FRACTURES OF THE PELVIS 



445 



minuted fractures are also seen. These fractures are generally the 
result of direct violence applied from the lateral aspect; although a 
case has been reported by Hamilton, in which there was a tearing off 
of a part of the crest and the anterior superior spine, and one by Cotton 
in which the anterior superior spine alone was torn off, the result of 
muscular action. Other cases have been reported by various authors, 
all of which occurred in young subjects and were in all probability due 




Fig. 573 

fracture of th 

with central displ 
the distance ' "" 
of the femur 



■Fracture of the pelvis. Incomplete central luxation of the head of the femur due to 
he acetabulum. Note the line of fracture extending through the floor of the acetabulum, 
displacement of the floor of the acetabulum and of the head of the femur. Lessening of 
between the superior rim of the acetabulum and the inner surface of the great trochanter 



to the action of the sartorius muscle, generally occurring during 
running. 

Isolated fracture of the ischium is rare. Few cases have been 
reported. The lesion consists in a fracture of the entire ischium in 
some cases, while in others only the tuberosity is fractured. They are 
usually the result of a fall upon the buttocks. 





s 




' 



FRACTURES OF THE PELVIS 447 

Isolated fractures of the coccyx are the result of a fall upon 
the buttocks, or a kick, or during parturition. Bony union of the 
coccyx with the sacrum occurs in late adult life in many cases, so that 
fracture at that point is possible. Many so-called cases are undoubtedly 
coccyodynia and partial dislocation. 

Symptoms. — Fractures of the pelvis as a rule are not accompanied 
by considerable displacement of fragments. Shock is a prominent 
symptom of fractures involving the ring of the pelvis, not so much 




Fig. 577. — Fracture of the anterior superior spine of the ilium. Direct violence. 

on account of the fracture itself as on account of the great force 
usually requisite in the production of these injuries, and because of the 
intrapelvic injuries and associated lesions. Displacement of fragments 
varies with the variety of fracture. In fractures of the rami, separa- 
tion of small portions of bone, as of the crest of the ilium, and tuber- 
osity of the ischium, deformity is not evident on inspection. Fracture 
anteriorly with displacement inward is evident on inspection. In the 
double vertical fracture of Malgaigne, there is usually marked dis- 



us 



TREATISE ON FRACTURES 



placement upward of the middle portion, including the hip. and the 
anterior superior spine and crest of the ilium are carried upward and 
outward. This is readily recognized on inspection. In transverse 
fracture of the ilium, inspection shows displacement upward with ap- 
parent lengthening of the leg. Transverse fracture of the sacrum may 
be recognized by the presence of a ridge at the seat of fracture. Frac- 
ture of the upper and posterior arm of the acetabulum simulates pos- 




Frc. 578. — N'ormal epiphyseal line of the crest of the ilium. This epiphysis unites with the dia- 
rtrt the twenty-first year. The line of the epiphyseal cartilage has often been mistaken tor a 
fracture. 

terior dislocation of the hip. while fracture of the acetabulum with 
penetration of the head through the acetabulum into the pelvic cavity 
show- loss of the normal prominence of the trochanter, shortening of 
the leg. relaxation of the fascia lata, and approximation of the great 
trochanter to the acetabular rim. and to the symphysis pubis 1 Fig. 
Fracture of the anterior superior spine may also at times be 
recognized on inspection. Separation at the symphysis pubis show- 



FRACTURES OF THE PELVIS 449 

broadening of the trochanters, with evidence of bulging at the sym- 
physis. 

Of chief importance as symptoms of fracture are the facts derived 
from careful palpation. Palpation should be carefully made in all 
cases. By this means abnormal mobility, crepitus, localized pain and 
tenderness may be elicited. Individual bones may be palpated by 
studying the uninjured side of the pelvis with one hand and with the 
other carefully going over the external aspects of the bone in the 
region of the suspected fracture. Lateral compression of the pelvis in 
the region of the crests of the ilia or of the trochanters will demon- 




FlG. S79- — Left innominate; old fracture; exostosis. It has been doubtless an old fracture of 
the crest of the ilium. On both sides of the seat of fracture, especially the outer, there are exostoses. 
There is also an exostosis of the pubis. (Mutter Museum, No. 1382.50.) 

strate many fractures (Fig. 581). Pressure directed upward in the 
line of the thigh with the hip and knee flexed will often produce pain 
and at times crepitus and abnormal mobility (Fig. 582). Palpation 
through the rectum or vagina may demonstrate irregularities of out- 
line and abnormal position of fragments, and elicit pain and crepitus. 
Examination by these routes enables the surgeon to palpate the pos- 
terior wall of the symphysis and rami of the pubes, the acetabulum, 
the arcuate line, the ascending ramus of the ischium, the sciatic notch, 
and posteriorly the coccyx and the promontory and upper portion of 
the sacrum. 

Of the subjective symptoms of fracture, there may be mentioned 
29 



450 



TREATISE OX FRACTURES 



pain, accentuated on pressure or movement, tenderness, inability to 
move the leg at times or to bear weight on the injured side, ecchymosis, 
and disturbed function. Inability to flex the leg may be due to nerve 
injury, to infiltration of the psoas muscle with blood, or to splinter- 
ing and puncture of the muscle by sharp fragments of bone. This 

Fig. 580. 




Fig. 580. — Method of measuring the distance from the median line of the abdomen to both 
trochanters to determine inward displacement of the trochanter in fracture of the acetabulum with 
dislocation of the head of the femur into the pelvic cavity. 





movement may also be impaired because the head of the femur will 
not stay in its normal position and has lust its point of purchase, as in 
fractures of ihe acetabulum. Walking is difficult and in most cases 
impossible on account of the pain and inability of the leg to properly 
support the weight of the body transmitted through the pelvis. 



FRACTURES OF THE PELVIS 451 

Areas of ecchymosis above Poupart's ligament are diagnostic of 
fracture of the pelvis and distinguish them from fractures of the neck 
of the femur, in which the ecchymosis is below the ligament. Later 
ecchymosis appears in the region of the scrotum, perineum, hip and 
sacrum, depending upon the site of fracture. 

In separation of the symphysis pubis there may be a palpable sulcus 
or furrow between the two innominate bones. In addition there is 
localized pain, tenderness on pressure, local ecchymosis, and abnormal 
movement on alternate rocking of the two sides of the pelvis, and 
especially on forced abduction of the thigh. 

Of particular interest are the fractures of the acetabulum asso- 
ciated with penetration of the fragments by the head of the femur into 
the pelvic cavity. The characteristic symptoms are apparent shorten- 
ing of the leg, loss of prominence of the trochanter major, loss of 
tension of the fascia lata, outward rotation of the thigh with loss of 
motion, and the presence on rectal or vaginal examination of the 
fractured acetabular floor and prominence of the head of the femur in 
the pelvic cavity. 

Fractures of the rim of the acetabulum simulate dislocation of the 
head of the femur, the usual lesion being a breaking off of the pos- 
terior and upper edge of the joint socket. The symptoms are those of 
dislocation of the head of the femur with crepitus, and a tendency 
toward recurrence of the dislocation after reduction. In this fracture, 
however, the limb assumes a position of outward rotation and ex- 
tension at the hip-joint, while in posterior dislocation of the head of 
the femur the limb lies in inward rotation with flexion at the hip ; and 
in fracture the trochanter is relatively nearer the anterior superior 
spine of the ilium than it is in this dislocation. 

Fractures of the crest of the ilium or its anterior superior spine are 
readily recognized by the abnormal displacement and mobility of frag- 
ments, and the situation of pain, tenderness, ecchymosis and crepitus. 

Complications. — Any real gravity of fractures of the pelvis is due, 
not to the damage done to pelvic bones themselves but to any injury 
to the pelvic contents, which so frequently accompanies these fractures. 
The chief complications of pelvic fractures are injury to the bladder 
and urethra, the rectum, the vagina, the iliac vessels, the vesical and 
pudendal vessels, the sacral nerves and the intestines. 

Lesions of the bladder may be the result of the force producing the 
fracture of the pelvis, particularly if urine distends the bladder, or 
may be due to puncture by sharp fragments of bone. When rupture of 
the bladder is due to direct force and is accompanied by fracture of 
the pelvis, the bony lesion will usually be found in the pubic rami, to be 
separation of the symphysis pubis, or occasionally in the sacrum or the 
acetabulum. Primary ruptures of the bladder are generally intraperi- 



452 TREATISE ON FRACTURES 

toneal, while secondary rupture, from perforation by sharp fragments 
of bone, are usually extraperitoneal. Bartel's statistics, based on 149 
cases of bladder injury associated with fracture of the pelvic bones, 
shows the pubes to have been the seat of fracture in 31 instances and 
separation of the symphyses in 2.2 instances. 

Injuries to the urethra associated with fracture of the pelvis may 
be the result of direct violence, as in a fall upon the perineum with the 
thighs separated. Such causation of injuries to the urethra from 
associated fractures are, however, rare. Lacerations are more gener- 
ally seen accompanying fracture, in which the force has been applied 
from side to side, or anteroposteriorly. The lesion usually occurs in 
the membranous portion of the urethra. The urethra may be com- 
pletely or incompletely torn across, and may be separated for a con- 
siderable distance from the surrounding soft parts. The most fre- 
quent lesions of the pelvis causing accompanying injury to the urethra 
are fractures of the descending ramus of the pubes near the symphysis 
and of the ascending ramus of the ischium. The fragments of bone 
may tear the urethra by compression or laceration, or the injury may 
be the result of displacement of the triangular ligament inward with 
the fragment of bone (Fig. 583). 

Injuries to the other pelvic contents are generally the result of 
tearing or crushing by displaced fragments of bone. The blood-vessels 
most commonly injured are the common iliac, the external iliac, the 
gluteal, the internal pudic, and the obturator arteries and veins. 
Lesions of the vagina and rectum are due to piercing of these structures 
by sharp fragments of bone. The nerves most frequently involved are 
the obturator, the sciatic nerves, and the sacral plexus. 

The symptoms of rupture of the bladder or urethra are difficulty 
of urination, hematuria or entire absence of any escape of urine, 
though the desire to empty the bladder may be urgent. In rupture of 
the urethra blood may trickle from the meatus. Bloody urine obtained 
by catheterization is always suggestive of rupture of bladder or 
urethra. Inquiry should always be made as to urination and when the 
bladder was last emptied before injury, if there is any lesion of the 
pelvis suspected. 

In rupture of the urethra the patient may be able to urinate, but 
the act is accompanied by marked pain and the urine will contain blood. 
The amount of urine will generally be small and will contain small 
amounts of coagulated or liquid blood. In suspected cases of rupture 
of the urethra or bladder, a metal catheter. No. 21 French, should be 
carefully introduced into the urethra. If it stops at the membranous 
urethra, and if on withdrawal the tip and eye are covered with blood, 
positive evidence of rupture is present. If the catheter passes into the 
bladder even after several failures and normal urine is obtained, but 



FRACTURES OF THE PELVIC 



453 



in addition there is trickling of blood from the meatus before catheter- 
ization and afterward, the evidence points to incomplete rupture of 
the urethra. 

In extraperitoneal rupture of the bladder, there will be no difficulty 
in introducing' the catheter into the bladder, but catheterization will 
show bloody urine. In intraperitoneal rupture, catheterization of the 
bladder will produce at first only a very small amount of bloody urme 
or at times only blood. Upon further introduction an elastic resist- 
ance will be felt which is the collapsed bladder wall. Possibly by deft 




Fig. 583. — Drawing to show rupture of bladder and urethra complicating fracture of the pelvis. 
A — extra- and intra-peritoneal rupture of the bladder with extravasation of blood into space of Retzius 
and between coils of intestine at (C) : B— rupture of the urethra anterior to the triangular ligament 
will give extravasation of blood and urine into penis, scrotum and superficial abdominal tissues as 
shown by dotted line. 

manipulation the tip of the catheter may be introduced into the opening 
into the peritoneal cavity, when blood and urine will be obtained, if 
sufficient time has elapsed since the injury for their accumulation. 
This latter procedure is not advocated. 

After twenty-four hours additional symptoms will be present. In 
rupture of the bulbous portion of the urethra there will be possibly 
swelling of the scrotum and penis due to urinary extravasation ; infil- 
tration above the symphysis and into the groins, and dulness of the 
lower part of the abdomen are indicative either of rupture of the 
urethra posterior to the triangular ligament or of extraperitoneal rup- 
ture of the bladder. In intraperitoneal rupture of the bladder there will 
be the symptoms of a rapidly increasing and severe type of peritonitis. 



4.54 TREATISE ON FRACTURES 

Diagnosis of intraperitoneal rupture of the bladder is frequently not 
made until too late to save the life of the patient. 

In a careful survey of the symptoms presented in suspected rupture 
of the urethra or bladder, one should bear in mind that dysuria or 
anuria may result from contusion of the abdominal wall or severe 
concussion of the pelvis, producing paralysis of detrusor vesicae muscle. 

Prognosis. — The prognosis of fracture of the pelvis depends to a 
great degree upon the site of fracture and the presence or absence of 
injury to the pelvic contents. In uncomplicated fractures the prognosis 
is always favorable so far as life is concerned. There is required in 
ordinary cases from six to eight weeks for union to take place, although 
the patient usually is incapacitated for a considerable time, depending 
to a great degree upon the region of fracture. Fractures involving 
the acetabulum, double vertical fractures of the pelvis, fractures of 
the sacrum, and those in the region of the sacro-iliac joint, as a rule, 
require a long time before convalescence is complete : and in many in- 
stances the working power of the individual is permanently diminished. 
In fractures of the acetabulum, permanent disability is often likely on 
account of immediate limitation of the range of the hip-joint and the 
possibility of the future development of arthritic changes due to ex- 
cessive callus. In fractures about the sacro-iliac joint, convalescence 
may be prolonged several years due to nerve pressure from fragments 
and callus. Coccyodynia is a usual sequel of fracture of the coccyx. 

Fractures of the pelvis with permanent displacement of fragments 
may. in the female, be followed by difficult labor in subsequent child- 
births. 

The most frequent complications of fracture of the pelvis are 
injuries to the bladder and urethra. When present they greatly 
diminish the likelihood of a favorable prognosis. Intraperitoneal rup- 
ture of the bladder is followed by a septic peritonitis, unless prompt 
laparotomy is performed. Extraperitoneal rupture of the bladder or 
rupture of the urethra is followed by urinary extravasation, and unless 
immediate repair is done, necrosis and suppuration of the soft parts 
occur. When perineal section is done for rupture of the urethra, there 
may be persistent urinary fistula or stricture resulting. Dr. Roberts 
has seen death from perforation of a duodenal ulcer secondary to pel- 
vic suppuration in front of the bladder after fracture of the pelvis 
with cystic laceration. 

Injury to blood-vessels may result in rapid and fatal hemorrhage 
or in subperitoneal hematoma, depending upon the vessel injured and 
whether the peritoneum is Is I rn. Aneurism of the injured vessel 
may develi »p. 

Injury to nerves may be followed by persistent motor paralysis. 
anaesthesia, or neuralgia. 



FRACTURES OF THE PELVIS 455 

Treatment. — The treatment of fractures of the pelvic bones con- 
sists of reduction of fragments when possible, maintenance of frag- 
ments in their normal position until union occurs, and the treatment of 
attendant shock and of the complications present. 

In reduction of displaced fragments, violent manipulations should 
be avoided, as they tend to increase shock and at times increase the 
extent of visceral injury. Careful manipulations, made through the 
rectum or vagina, aided by traction applied to the leg and thigh, may 
reduce displaced fragments of bone. In fractures of the rim of the 
acetabulum, double vertical fractures involving the entire pelvic rim, 
and in fractures of the acetabulum, with perforation of the head of the 
femur through the acetabulum into the pelvis, reduction should be 
first accomplished; then the foot of the bed should be elevated for 
counter-traction and a Buck traction apparatus applied to the leg and 
thigh with sufficient weights (15 to 20 lb.) to maintain reduction. In 
fractures of the rami of the pubes or ischium, of the sacrum, in frac- 
tures in the region of the sacro-iliac synchondrosis, and in separations 
of the symphysis pubis, the patient should be placed flat on the back, 
with knees and thighs partially flexed by a pillow under the knees, and 
support to the pelvis be made by encircling bands of firm muslin or ad- 
hesive plaster strapping ( Figs. 584 and 585 ) . In some instances immo- 
bilization may best be maintained by the use of a gypsum case applied 
around the entire pelvis, from a point above the crest of the ilium to 
below the trochanters. In some cases reduction of fragments may be 
further accomplished by the use of packing in the rectum, or vaginal 
packing in women. This rectal support, however, should be carefully 
applied, and changed at least every other day ; the packing should have 
in its centre a rubber tube to facilitate the escape of flatus. 

In fractures of the crest of the ilium the encircling bandage should 
not be used, as it tends to increase the deformity. Support in this form 
of fracture is best obtained by the use of properly applied sand-bags. 
In perforating fractures of the acetabulum, with the head of the femur 
in the pelvic cavity, lateral traction outward on the upper part of the 
thigh should be used in addition to counter-traction and the Buck 
traction apparatus. Fractures of the anterior superior spine of the 
ilium are best treated by flexion of the hip and leg and the use of an 
encircling gypsum case. The separation fragment may be held in 
position by subcutaneous nailing with a wire nail or screw. Fractures 
of the tuberosity of the ischium should be treated by flexion of the leg 
on the thigh and by extension of the thigh at the hip so as to relax the 
ham-string muscles. Fractures of the coccyx are best treated by 
excision of the coccyx. 

When intraperitoneal or extraperitoneal rupture of the bladder is 
present, exploratory laparotomy should be performed. In intraperi- 



456 



TREATISE OX FRACTURES 



toneal rupture a vertical incision should be made in the median line 
through the abdominal wall, the pelvic cavity cleansed with moist 
sponges, and the rent in the bladder closed by two layers of inter- 
rupted Lembert sutures, the inner layer being of chromic catgut, the 
outer layer of silk. The abdominal wound should then be closed with 
a cigarette drain placed in the pelvic cul-de-sac. Catheterization 
should be performed every eight hours afterward for at least ten days. 
In extraperitoneal rupture, exposure is best obtained by a transverse 
suprapubic incision, and the tear when found should be closed in the 
same manner as described above for intraperitoneal rupture. The 
after-treatment should be the same. 





Fig. 585. — Completed adhesive plaster swathe for fracture of the pelvis. 

To obtain success in the presence of these two complications, op- 
erative interference should be performed within the first twenty-four 
hours. In rupture of the urethra, perineal section should be done as 
soon as shock has disappeared. The proximal end of the torn urethra 
should be sought for, and when found a male catheter should be 
passed through the urethra from the external meatus to the bladder. 
When possible the two torn portions of the urethra should be united 
by chromic catgut and the perineal wound packed. Otherwise a free 
exit should be left for drainage of urine through the perineal wound. 
When the proximal end cannot be found a suprapubic cystotomy 
should be performed and retrograde catheterization done. The cath- 
eter should be maintained in the urethra for ten days to two weeks. 
and after this time careful dilatation with sounds should be made to 
prevent the occurrence of stricture in the urethra. 



CHAPTER XXI 

FRACTURES OF TFIE FEMUR 

Anatomy. — The femur (Fig. 586) is the largest of the long bones. 
It articulates with the innominate bone above and the tibia below. It 
consists of an upper extremity, a shaft, and a lower extremity. 

The upper extremity is divided into the head, the neck, and the 
greater and lesser trochanters. The head extends inward and upward, 
surmounting the neck, and consists of about two-thirds of a sphere. It 
is covered with fibrocartilage, excepting at the attachment of the 
ligamentum teres just below and to the inner side of its centre. The 
neck, shaped like an oblique truncated cylinder, is the constricted 
portion between the head and the shaft, and forms an obtuse angle 
with the shaft of about 120 degrees in the adult. This varies during 
life from 160 degrees at birth to no degrees later in life. The great 
trochanter is the upper external portion of the shaft of the femur at its 
junction with the neck. The small trochanter is a projection at the 
junction of the inner and posterior surface of the shaft of the femur 
opposite the great trochanter. Between the two trochanters anteriorly 
runs a ridge called the intertrochanteric line, and posteriorly a more 
marked ridge termed the intertrochanteric ridge. 

There are separate epiphyseal centres for the head and the greater 
and the less trochanters, while the condyles have a common epiphysis. 
The time for union for the great trochanter is the eighteenth year, 
for the small trochanter the seventeenth year, and for the head the 
eighteenth year. The condylar epiphysis unites with the shaft about 
the eighteenth or twentieth year. The femur bears the entire weight 
of the body in the upright position. The weakest portion of the bone, 
because of its structure and position, is the neck. This, however, is 
specially strengthened, not only by its shape, but also by the lateral 
construction of the spongy structure, which is arranged with trabecular 
to bear pressure and tension in the definite lines needed. The head 
receives its blood supply through an artery in the round ligament and 
through the circulation in the cancellated structure. 

In later years the vessels in the ligament disappear almost entirely, 
so that the nutrition of the head is dependent upon the blood supply 
from the spongy tissue of the neck. 

The shaft of the femur is arched convexly anteriorly, is nearly 
cylindrical, and toward its lower end, becoming broader, presents a 
three-sided prism with three surfaces, two lateral and one ventral. 
Posteriorly is seen the longitudinal linea aspera, formed by the junction 

457 



458 



TREATISE OX FRACTURES 



of the spiral line and gluteal ridge; below, the linea aspera divides into 
internal and external condylar ridges. 

The lower extremity of the femur is broad and consists of the two 
masses of bone, the internal and the external condyles. These are 
more prominent posteriorly and are separated by the deep intercondylar 
notch, while anteriorly the}- are united by the trochlear or articular 
surface of the patella. Upon the condyles on each side there is a 



Greater trochanter 
Superior cervical tubercle 




Fossa for round ligament 



Lesser trochanter 



. Adductor tubercle 
Patellar surface . 

External condyle , — '^Mjl^ s < ^^ f ' Internal condyle 

Fig. 586. — Right femur, anterior view. 

prominence on the lateral surface, the internal epicondyle and the 
external epicondyle. 

The hip-joint is the articulation between the acetabulum and the 
upper end of the femur. Its ligaments consist of the glenoidal or 
cotyloid ligament, which is a circular fibrocartilage deepening the 
acetabular cavity, the round ligament or ligamentum teres inserted in 
the head of the femur, and the capsular ligament attached to the outer 
surface of the glenoid ligament, which surrounds the neck of the 
femur, excepting a small part posteriorly. In addition are the three 
accessory ligaments, the iliofemoral or the inverted Y or Bigelow liga- 



FRACTURES OF THE FEMUR 



459 



ment, which strengthens the capsule, the pubocapsular, and the ischio- 
capsular ligaments. The knee-joint is the articulation between the 
condylar surface of the femur and the tuberosities of the tibia below 
and the trochlear surface of the condyles and the posterior surface of 
the patella in front. Upon the upper articular facets of the tibia are 
two menisci, called the internal and external semilunar fibrocartilages. 

The ligaments of the knee-joint are : the internal lateral ligament, 
the external lateral ligaments, the 
posterior ligaments, the ligament of 
the patella, the capsular ligament, 
the synovial or alar ligaments, the 
anterior crucial ligament, and the 
posterior crucial ligament. 

Surface Markings. — The princi- 
pal landmarks to be remembered 
in fractures of the femur are the 
anterior spine of the ilium, the spine 
of the pubes, the tuberosity of the 
ischium, the great trochanter of the 
femur, the umbilicus, the patella 
and the internal malleolus. These 
points are of value in determining 
shortening of the bones of the 
thigh and leg. On the outside of 
the thigh about four inches below 
and posterior to the anterior super- 
ior spine of the ilium will be found 
a marked prominence, just below a 
depression ; it is the great trochanter 
of the femur. The relations of this 
trochanter to other landmarks are 
of great importance, for they determine to a great extent the presence 
of fracture and luxation. 

A number of aids are in use for determining the existence of frac- 
ture of the neck of the femur. The most important of these are the 
relation of the trochanter of the injured limb to the Roser-Nelaton 
line and the Bryant triangle. These topographical markings are used 
particularly in determining the presence or absence of elevation of the 
great trochanter on the injured side. The Roser-Nelaton line (Figs. 
587 and 588) is a line drawn from the anterior superior spine of the 
ilium to the tip of the tuberosity of the ischium. Normally the upper 
border of the great trochanter should touch this line, and this relation 
is not disturbed by flexion and extension of the thigh. Comparison of 
the two sides will usually show a displacement upward of the trochanter 




Pig. 587. — View of outer surface of the bones 
of the hip showing Roser-Neiaton line (a-d); 
Bryant's triangle (abc) ; ilio-trochanteric line (a-c) 
and the ilio-trochanteric angle (bac)." (Davis.) 



460 



TREATISE ON FRACTURES 



in fracture of the neck of the femur. The two sides must be examined 
with the two limbs perfectly parallel to each other and at right angle to 
a line drawn across the top of the pelvis, either at the level of the 
crests of the ilia or from one anterior superior spinous process to the 
other (Fig. 589). Abduction or adduction of either side will alter the 




Fig. 588. — Outer surface of right hip and thigh, showing Roser-Xelaton line and Bryant's triangle. 

results and render the test valueless. Bryant's triangle (Figs. 587 and 
588) is formed by dropping vertically a line from the anterior superior 
spine of the ilium to the bed or table on which the patient lies supine ; 
a second line is drawn at right angle to this line, running in the axis of 
the thigh to the great trochanter to this primary line, and a third line 





FlG. 589. — In making measurements from the anterior superior spine of the ilium to the internal 
malleolus to determine shortening on the injured side, the two lower limbs should be parallel to each 
other and at right angles to a line drawn through the anterior superior spines, as in .4. If tilting of 
the pelvis is present as in H incorrect conclusions will be made. 



is drawn from the anterior superior spine of the ilium to the great 
trochanter, thus forming a triangle. In fractures of the neck of the 
femur the second line is found to be shortened in comparison with that 
of the sound side ( Fig. 599). 

Relaxation of the fascia lata as a test or proof of shortening due 



FRACTURES OF THE FEMUR 



461 



to fracture of the femur was first suggested by Allis. This relaxa- 
tion is best observed between the crests of the ilium and the great 
trochanter, and also above the outer condyle of the femur (Fig. 591). 
Another measurement used to determine shortening of the leg from 
fracture of the femur is that between the anterior superior spine of the 
ilium and the internal malleolus (Fig. 592). Comparison with the 
sound side will determine the presence of shortening in fractures of 
the femur or of the bones of the leg (Fig. 593). Measurement be- 
tween the anterior spine of the ilium and the adductor tubercle is at 

Fig. 590. Fig. 591. 




Fig. 590. — To demonstrate elevation of the great trochanter in fracture of the neck of the femur. 
Not only is there elevation of the trochanter but it is in closer contact with the upper rim of the ace- 
tabulum. Dotted line shows normal position. 

FlC. 591. — Showing relaxation of the fascia lata which occurs in fracture of the femur. Allis method 
of determining the same. (Roberts.) 

times used to demonstrate shortening in fractures of the femur. When 
making these measurements, the patient should be placed on a flat 
table and care be taken to place the lower limbs exactly parallel to each 
other and at right angle with the transverse axis of the pelvis or a line 
drawn through the acetabula. It must be recollected that uninjured 
femurs may be asymmetrical in length, and that usually the surgeon 
has no information whether the longer or shorter femur has been 
broken. This has been proved by measuring the bones of skeletons in 
which there has been no injury prior to death. The tibia on one side 



462 TREATISE ON FRACTURES 

may be longer than that of the other leg, therefore a difference in the 
length of legs after a fracture may be due not to a broken femur but 
to a normally short tibia. These known anatomical variations must be 
reckoned with in investigating possible fractures. 

The shaft of the femur is well covered by muscles, so that the shaft 
can be only indefinitely felt with the fingers. At the lower end of the 
femur the internal and external condyles may be readily palpated, as 
well as the adductor tubercle. 

Statistics. — Plagemann's statistics from Midler's clinic at Rostock, 
based upon the radiographic diagnosis of 1393 cases, shows that the 
femur was fractured in 150 instances (10.81 per cent.), as follows : 

Per cent. 

1. Fractures at the upper end 84 61.04 

(1) Fractures of the neck of the femur 60 4.307 

(a) Fractures, collo-subcapital II 0.78 

(b) Fractures, collo-intermediate 20 1.43 

(c) Fractures, collo-intertrochanteric 5 0.359 

(d) Fractures, collo-trochanteric 24 1.79 

(2) Separation of the upper femoral epiphysis 4 0.29 

(3) Fracture of the femur, per-trochanteric 7 0.509 

(4) Fracture of the greater trochanter 2 0.143 

(5) Fracture of the femur, subtrochanteric 11 0.78 

2. Fractures of the shaft of the femur 55 3.94 

3. Fractures of the lower end of the femur 11 0.89 

(1) Supracondylar fracture of the femur 7 0.509 

(2) Separation of the lower epiphysis of femur 2 0.143 

(3) Fractures of the condyles of femur 2 0.143 

Fractures of the femur will be considered as follows : fractures of 
the upper end of the femur; fractures of the shaft of the femur; 
fractures of the lower end of the femur. 

Fractures of the Upper End of the Femur 
Fractures of the Head of the Femur. — This injury is extremely rare 
(Fig. 594) . The reported cases occur not as independent fractures but 
in conjunction with dislocation of the femoral head, especially of dislo- 
cations from direct thrust, says Cotton. They partake of the nature 
of a compression fracture, and are due to such trauma as a direct fall 
upon the trochanter or being run over by a heavy wagon. A case 
reported by Riedel showed longitudinal splitting of the head and 
neck. The symptoms were shortening to about two inches, inward 
rotation, flexion, and indistinct crepitus. The treatment in this case 
consisted of excision of the upper fragment with reposition of the 
remainder of the head into the acetabular cavity. Recovery followed 
with ankylosis and shortening of 2 cm. Other cases are reported 
by Braun and by Stimson. Tt is possible that nailing through the 
great trochanter and neck might be available. 



FRACTURES OF THE FEMUR 



463 



Fractures of the Neck of the Femur. — Fractures of the neck of 
the femur (Figs. 595-597) are observed during all decades of life. 
In children rare, in early adult life they are fairly frequent, but the great 
majority are found in late adult life, particularly after the age of fifty- 
five years. Recent investigations based upon radiographic examina- 
tion have shown a comparative frequency of these fractures during 




Fig. 592.- 



-Method of measuring from the anterior superior spine of the ilium to the internal malleolus. 
A flexible steel tape should be used. 



childhood. Before the use of the Rontgen ray these usually were 
considered to be contusions of the hip or epiphyseal separations of the 
femoral head. Haldenwang and Whitman's observations on this sub- 
ject have been very enlightening. Haldenwang collected a series of 
25 cases occurring between the ages of one and eighteen years ; and 





of these 2$ were fractures of the femoral neck. Seven were found in 
children ten years of age or younger, and 17 were between ten and 
eighteen years. Of them 15 were observed in females. In the ma- 
jority the fracture was at the base of the neck, a few were close to the 
head, and the remainder were intermediate fractures. All excepting 



464 TREATISE OX FRACTURES 

six were only recognized long after the injur}", when an operation was 
about t-o be performed for the resultant coxa vara. Cervical fracture 
is. however, one essentially of late adult life, and is more common in 
women than in men. It constitutes one-third of all fractures occurring 
in persons over seventy years. 

Etiology. — Very few patients are able to tell just how their femurs 
have been broken. Experiments have been made which show that 
fractures of the femoral neck may occur from a variety of forces, 
may be produced by direct force applied to the trochanter, by a 
blow on the knee., by extreme abduction or by undue hyperextension. 
Some authorities contend that these fractures are in some instances 
the result of strain exerted through the ligaments when the limb is in 
an extreme position, and that the fall is the result of the fracture and 
not the fracture the result of the fall. In the majority of cases, how- 
ever, the fracture is probably the result of a mis-step, a fall to the 
ground while walking, or a slight jar. In the very young, moderate 
_l__— ^____| forms of violence may be the exciting cause of 
I these cervical fractures. Those observed in early 
I adult life are generally the result of more ex- 
I treme violence, such as a fall upon the trochan- 
I ter, or upon the buttocks. In the aged little 
I force is required to cause the injury. Often a 
^^^j I mis-step and the subsequent effort to regain one's 

I balance may be the only form of violence to 
^^^^™^^^^^* which the femur has been subjected. 

'■ ' [ Fractures by muscular action are occasion- 

ed^* ally observed in cases in which the capsule and 
emu. No. 1397.0035.; Y-ligament are unduly stretched by the mus- 

cular pull. Dr. Allis. of Philadelphia, has within recent years made 
valuable observations on the causation of fractures, but has not 
yet published them. 

The contributing cause of fracture, in persons over fifty years of 
age. is the change which takes place in the composition of the bones 
of the entire skeleton. In the neck of the femur these changes arc 
particularly important, in that they greatly les-en the strength of the 
neck of the femur, which depends upon its anatomical construction to 
support the whole weight of the body in walking and to repel all 
sudden strains and stresses placed up m it. 

After the fiftieth year there occurs an eccentric atrophy of bone. 
The cortex of the neck of the femur becomes thinner, and the lamellae 
of the spongy interior are to a great measure absorbed and replaced by 
large cavities containing yellow bone-marrow. This rarefaction of 
osseous tissue, with the consequent loss of strength, is a much more 
potent factor in the frequent occurrence of fractures of the neck of 



FRACTURES OF THE FEMUR 



465 



the femur than the changes o f angle which occur between the shaft and 
neck with advancing life. This degenerative change is the predispos- 
ing cause which permits slight injuries to have such disastrous results. 

Varieties. — Classification of fractures ot the femoral neck, based 
upon radiographic findings given by Plagemann is : ( I ) fractures collo- 
subcapital (Fig. 598) ; (2) fractures collo-intermediate (Figs. 599- 
601) (the earlier fractures of the neck of the femur) ; (3) fractures 
collo-intertrochanteric (Fig. 602) (after Kocher) or basal fractures of 
neck of femur (after Konig) without accompanying fracture of the 
trochanteric region; (4) fractures collo-trochanteric (Figs. 603-605). 

[The first, or collo-subcapital, form of fracture is intracapsular, 
located near the head of the bone, with an irregular fracture line run- 
ning transverse or slightly oblique. 




Fig. 595- — Femur, intracapsular fracture of the neck; ununited. The line of fracture is close to the 
head and is transverse. (Mutter Museum, No. 1397.003.) 
Fig. 596. — Femur, right: Fracture of the base of the neck. (Mutter Museum, No. 1397.0^55 ) 
Fig. 597-— Femur, upper third of: intracapsular fracture of the neck; ununited. The neck 

of the femur has been absorbed, allowing the head of the bone to sink so as to nearly touch the 

trochanter minor. The fracture] is wholly within the capsule. There is no bonv union. (Mutter 

Museum, No. 1397.004.) 

The second, or collo-intermediate, the so-called mixed fracture of 
the neck of the femur, has a fracture line irregularly oblique, running 
through the middle of the femoral neck. This fracture is similar to the 
partially intra- and partially extracapsular fracture of the earlier classi- 
fication of mixed fractures. On account of the lower insertion of the 
joint capsule in front than behind, the line may be intracapsular in front 
and extracapsular behind. 

The third, the fracture collo-intertrochanteric (Kocher), has a line 
running through the base of the neck of the femur along the intertro- 
chanteric line, ending near the lesser trochanter, without an accom- 
panying fracture of the trochanteric region. 
30 



466 



TREATISE OX FRACTURES 



The fourth, the so-called fracture collo-trochanteric, has a frac- 
ture line which runs through the base of the femoral neck on one side, 
and through the region of the trochanter on the other side, and usually 
takes the form of the letter T, K. or L. In this form there is at the 
same time a complete or partial breaking off of both trochanters, com- 
bined with more or less numerous separate fissures, running into the 
femur. 




Fig. 598. — Fracture of the neck of the femur. (Collo-subcapital junction of the head and the neck ) 

In addition to those of the above classification there are fractures 
which show other than the usual characteristics: but in the main, the 
classification given above covers the varieties as well as is possible. 
The exceptions to these four varieties may be looked upon as irregu- 
lar varieties. Most fractures will be found to come under one of two 
heads — fractures of the narrow part of the neck, and fractures at the 
base of the neck. The older terms, intracapsular and extracapsular, 
should be discarded. 



468 



TREATISE ON FRACTURES 



Impaction and fixation of fragments at the time of the injury is 
very frequent in fractures of the base of the neck and not infrequent 
in those of the subcapital variety. When impaction occurs, the re- 
sulting- eversion or inversion depends upon whether the posterior part 
or the anterior part of the neck suffers greater destruction. When 
there is eversion present, destruction of the posterior wall of the neck 
is the,greater, and when inversion is present destruction of the anterior 
part of the neck is present. The presence of eversion or inversion is 
due to the direction of the fracturing forces and the form of rotation 
present at the time of fracture. Nearly all fractures of femoral neck 
if not disturbed by handling will probably be found to be impacted or 
the fragments at least entangled. 




Base of the neck.) 



When the fracture line occupies the apex of the neck there is 
great liability of interference with the blood supply of the head. 
Usually there remains some blood supply through the ligamentum 
teres and through portions of untorn capsule and periosteum. In 
fractures at the base of the neck, interference with the blood supply 
is not so liable to take place as the line of fracture is partially without 
the capsule of the joint. Impaction of fragments is more frequently 
present as the fracture line approaches the trochanters. Fractures at 
the apex of the neck show frequently absence of impaction or incom- 
plete impaction. Fractures toward the base are generally impacted. 
This impaction may be complete or incomplete. 

In fractures in which impaction is complete the upper fragment of 



FRACTURES OF THE FEMUR 



469 



the neck is driven into the trochanteric fragments, which are usually 
twisted backward, and with the shaft of the femur rotated outward. 
The angle of the shaft and neck approaches more nearly a right angle 
and the distance between the trochanters and head is lessened. When 
impaction is incomplete it is due either to violent manipulation of the 
part or more frequently to the fact that it does not involve the entire 
circumference of the neck, so that only one side, generally the pos- 
terior part, and the upper fragment, is impacted into the trochanteric 
fragments. When impaction is absent, particularly in fractures at 
the base of the neck, the trochanteric fragment with the shaft is drawn 
upward, displaced backward, and rotated outward. This position is 





Involving both 



due to muscular pull, and the weight of the extremity, which tends to 
rotate outward from its own weight when the patient is lying on his 
back. 

Symptoms. — Localization of the exact seat of fractures of the 
neck of the femur is almost impossible by clinical symptoms alone. 
This is due to the shortness of the fragment and its depth in the 
tissues. In cases of suspected fracture, and indeed in all injuries 
about the hip-joint that cause disability, radiographic examination 
should be made. It is only by adhering strictly to this rule that the 
exact variety of a fracture and the presence or absence of impaction 
may be determined. In a small number of cases radiographic exam- 
ination will not be possible, on account of the age of the patient or 



470 TREATISE ON FRACTURES 

other difficulty of transportation, and in these cases diagnosis must 
he made from the clinical symptoms. 

The symptoms of fracture of the neck of the femur are impair- 
ment of motion, muscular relaxation, false motion, eversion or in- 
version, shortening, crepitus, pain, tenderness on pressure, swelling. 
ecchymosis. 

Impairment of Motion. — As a rule the patient is unable to lift the 
extremity from the bed or to bear the weight of the body upon it. At 
times he is able to slightly elevate the thigh from the bed. particularly 
if he can obtain a purchase on the bed with the heel. Flexion of the 
thigh is at times possible when the thigh is in a position of abduction. 
Ability to raise the foot from the bed is usually impossible. W "hen 
impaction of fragments is absent, motor disability is more marked 
than in those cases where it is present. In some instances patients 




Fig. 606. — Showing method of determining false motion in fractures of the neck of the femur. 
One hand is placed upon the great trochanter while the other produces alternate inward and outward 
rotation of the thigh. Lessening of the arc of rotation will also be determined. 



have been known to walk on the injured limb, hut in these instances 
firm impaction was present. 

Muscular Relaxation. — With the shortening of the distance be- 
tween the iliac crest and the great trochanter muscular relaxation takes 
place, particularly of the gluteals and of the tensor of the fascia of 
the thigh. This relaxation is noted by the presence of an abnormal 
depression above the great trochanter, and above the outer condyle 
of the femur ( Fig. 591 ) 1 Allis). 

Cleemann has called attention to a wrinkling of the skin over the 
patellar ligament in fractures of the neck of the femur, which will be 
obliterated when extension is made. This is due to the same physical 
cause as the lessening of tension of the fascial sheath on the outside 
of the thigh, namely, the shortening of the length of the thigh bone 
by over-riding at the point of fracture. 



FRACTURES OF THE FEMUR 



471 



False Motion. — This is demonstrated by rotation of the thigh with 
one hand while the other hand is placed upon the great trochanter 
(Fig. 606). In impacted fractures of the neck of the femur this arc 
of rotation will be less than on the normal side and will be the arc of 
a circle whose radius is the distance from the line of fracture to the 
surface of the trochanter. In unimpacted fracture, the shortness of 
the arc of rotation will be even more marked; it is more evident the 
nearer the fracture is to the trochanter (Fig. 607). 

Evasion and Inversion. — An increased eversion of an injured 
limb is usually pathognomonic of fracture. When a person lies on his 
back both thighs are usually slightly everted by gravity. There is 
usually a slight degree of abduction and flexion at the hip, with marked 
eversion of the entire extremity, when the neck of a femur has been 
fractured. In impacted fractures, the limb rests upon its outer side 
with the little toe almost touching the mattress and the heel is on a 
level with the hollow between the internal malleolus and the tip of the 




Fig. 607. — Drawing to show why the arc of rotation is shortened in unimpacted fractures of the 
neck of the femur. In A the centre of rotation is at the acetabulum, while in B, C and D the 
centre of rotation is about the axis of the femoral shaft. In inpacted fractures the centre of rotation 
is at the acetabulum but the arc is less than normal. 

calcaneum of the sound foot. In unimpacted fractures, eversion is 
absolute and the limb is generally not flexed or abducted at the thigh. 
This eversion is due to the fact that crushing and impaction of the 
posterior portion of the neck are usually greater than involvement of 
the anterior part of the neck, and also by the fact that gravity is un- 
resisted by the normal supporting agencies of the limb. In a few in- 
stances inversion, which may be marked, is seen. This is usually due 
to impaction of the front of the fracture from the trauma being the 
result of a blow on the back of the hip. In all cases comparison with 
the uninjured limb should be made to determine whether eversion is 
apparent or real, whether the extent of possible eversion is greater or 
less on the injured side, and whether the supposed fracture interferes 
with or increases toward rotation. Violent manipulation to determine 
false motion, eversion, or inversion is strongly condemned. It is often 
wiser to delay making a positive diagnosis than to break up impaction 
or tear the periosteum at the seat of fracture. 



472 TREATISE ON FRACTURES 

Shortening. — Shortening is one of the most important diagnostic 
signs in fracture of the neck of the femur. It depends upon changes 
in the angle of the neck with the shaft and upon over-riding of frag- 
ments. In impacted fractures the shortening is usually less than one 
inch, while in unimpacted fractures it may be from one and a half to 
three inches. Primary minimum shortening in impacted fractures, 
changing later to a great degree of shortening, indicates either partial 
or complete abolition of impaction. Bardeleben states that in frac- 
tures of the narrow part of the neck within the capsule, longitudinal 
displacement is prevented by the action of the intact portion of 
the capsule or by the impingement of the upper fragment against 
the small trochanter. Later, if the capsule yields or the fragments 
are unlocked the shortening increases. In taking measurements to 
determine the presence of shortening, attention should be paid to 
the normal differences which exist in the same individual in the length 
of the two femurs and of the two tibias. 

The most trustworthy methods to determine the presence of short- 
ening due to fracture of the neck of the femur are : ( i ) Measurement 
of the distance from the anterior superior spine of the ilium to the 
tip of the internal malleolus (Fig. 592), on both sides. In fracture 
of the neck of the femur the distance between these two points will be 
less on the affected side. (2) The relation of the great trochanter to 
the Roser-Nelaton line (Figs. 587 and 588). In fracture the great 
trochanter will be above this line. (3) Measurement by means of 
Bryant's triangle (Figs. 587 and 588). In this test the distance from 
the tip of the great trochanter to the vertical line dropped from the 
anterior superior spine of the ilium with the patient flat on his back 
will be less on the affected side. In making use of the above three 
tests the patient should lie upon a firm, flat surface, such as a table, the 
two lower extremities parallel to each other and to the line of the spine 
and at right angles to a line drawn through the two anterior superior 
spines of the ilia. Shortening may also be determined by the Allis and 
the Cleemann tests noted above. 

Crepitus. — Crepitation is an important symptom of fracture of the 
neck of the femur when it can be elicited. It is not obtainable in the 
presence of impaction of fragments, or in those cases of non-impaction 
where the fragments are over-riding and cannot be brought into appo- 
sition by traction. It should not be sought for, as a rule, because of 
the danger of separating impaction of fragments and tearing adherent 
bands of periosteum. When impaction is not present it can generally 
be demonstrated by pressure back of the great trochanter or by trac- 
tion with or without rotation. It may be simulated in manipulation 
by the rubbing of the outer fragments upon the ilium. Crepitus in 
unimpacted fractures may more readily lie determined in fractures 



FRACTURES OF THE FEMUR 



473 



involving the base of the neck and trochanters than in those of the apex 
of the neck. 

Pain. — In fractures of the neck of the femur pain is generally 
present. It is greater in fractures involving the base of the neck ; and 
in these cases is generally at the outer and upper part of the hip, while 
in fractures of the neck the pain is generally in the inguinal region. 
Pain is increased by active or passive movements of the thigh. 

Tenderness. — Tenderness on pressure 
is generally localized outside of the femoral 
vessels. 

Swelling. — Localized swelling is gener- 
ally present in all fractures of the neck of 
the femur. It is greater in fractures ap- 
proaching the trochanteric region. The 
fold of the buttock is less pronounced than 
on the sound side. 

Ecchymosis. — Ecchymosis only appears 
after several days have elapsed and it ap- 
pears more constantly in proportion to the 
proximity of the fracture to the great tro- 
chanter. When the line of fracture is 
mainly intracapsular, the area of ecchy- 
mosis is limited to the groin below 
Poupart's ligament and inner surface of 
thigh, while in fractures of the base of the 
neck, which are mostly or wholly extracap- 
sular, the area of ecchymosis is limited 
generally to the trochanteric region, but 
may be diffuse by being scattered over the 
outer surface of the thigh and buttock. 

Diagnosis. — In the presence of the 
above symptoms diagnosis is seldom diffi- 
cult. Even when the symptoms are slight 
in character a positive diagnosis of fracture 
of the neck of the femur usually may be 
made by careful examination. An anaes- 
thetic is not required and violent manipu- 
lations to determine crepitus should never 
be made. In practically all instances a 
radiographic examination will determine the presence and site of the 
fracture. When there is any doubt as to the existence of a fracture, 
it should be traced as such until an absolute diagnosis is made by the 
subsequent history. A correct diagnosis of the site of the fracture 
may often be made from the clinical signs by careful consideration 




Fig. 608. — Anterior luxation of the 
right hip-joint. Note typical attitude, 
apparent shortening, eversion of the 
foot. 



474 TREATISE ON FRACTURES 

of the symptoms. The exact line of break is not so important as 
some surgeons seem to think. The treatment does not vary much 
in the different varieties of femoral fracture. 

Fractures of the neck of the femur should be carefully differen- 
tiated from luxation of the hip (Fig. 608), unilateral fracture of the 
pelvis, and contusion of the hip. Fractures usually may be differen- 
tiated from posterior dislocation of the head of the femur by the 
presence of eversion; for inversion in the fracture is rare. When it is 
present, flexion adduction and fixation, such as are found in posterior 
luxations, are absent, and the head of the bone is not found over the 
dorsum of tbe ilium or sciatic notch as in posterior dislocation; and in 
fracture with inversion, traction may break up the impaction, changing 
the inversion to eversion and correcting the shortening -which it would 
not do in posterior dislocation. Dislocation is rare in the aged but frac- 
ture is common as a result of injury. Tbe symptoms already described 
and the X-ray will reveal the condition. Fractures with eversion may 
be mistaken for anterior dislocation of the head of the femur. The 
anterior dislocations are, however, rare and are accompanied by flat- 
tening of the trochanteric region, abduction and flexion of the thigh 
and the presence of an abnormal prominence at the site of the displaced 
head of the femur on the pubes or in the obturator foramen. In dis- 
locations there is always marked limitation of passive motion, and the 
limit of possible mobility is always noted by a sudden arrest of move- 
ment felt by the hand of the examiner. The axis of the head of the 
femur and that of the inner surface of the internal condyle normally 
point always in the same direction: attention to this fact will deter- 
mine the position of the head of the bone in dislocation of the head 
of the femur. In fractures the direction of these two areas may be 
different. 

Fracture of the femoral neck should be carefully diagnosticated 
from fracture of the pelvis. The fractures of the pelvis with which it 
may be confused are fracture of the rim of the acetabulum and frac- 
ture of the acetabulum with partial or complete penetration of the head 
of the femur through the acetabulum into the pelvic cavity. In these 
cases a careful examination of the patient and a radiogram will make 
clear the diagnosis. 

Fractures of the neck of the femur should be differentiated from 
contusion of the hip. In contusion there may be impairment of motion, 
elevation of the pelvis on the side affected, outward rotation and 
flexion of the thigh, severe pain, and at times muscular spasm. Frac- 
ture, however, it is well to remember, often occurs in elderly people as 
a result of a moderate degree of violence, and instead of improvement 
taking place the functional condition becomes worse. In simple con- 
tusion a relatively severe degree of violence is present and the function 



FRACTURES OF THE FEMUR 475 

of the part tends to improve after several days. In addition the 
symptoms of contusion generally are localized in the area injured. 

A recent fracture of the neck of the femur should be differentiated 
from a previous fracture, or from an arthritis deformans to which a 
local contusion has been added. Skiagraphy and the clinical circum- 
stances will aid in the determination of the true character of the pa- 
tient's disability. 

Fractures below the trochanters may be differentiated from those 
of the neck by the fact that rotation of the trochanter does not occur 
when the shaft of the femur is rotated by the surgeon, and the evi- 
dence that rotation of the shaft occurs upon its longitudinal axis. 

Prognosis. — Many fractures of the neck of the femur are observed 
in persons of advanced life. The problem is not so much to obtain 
perfect anatomical apposition of fragments and a perfect functional 
result as to prevent the development of conditions which, with con- 
finement to bed and the incidental shock of the injury, may produce 
death. Many of the deaths in these cases are due to hypostatic pneu- 
monia, to development of mental and physical shock which produces 
death in a few days, or to sepsis from extensive bed-sores. A few 
cases are undoubtedly due to fat embolism or to acute dilatation of a 
fatty degenerated heart. It is unquestionably true that close confine- 
ment to bed in the recumbent position, with cumbersome and fixed 
dressings for a long period, will tend toward hypostatic pneumonia, 
bed-sores, and fatty degeneration of the heart. Patients of the age in 
which this form of fracture is so frequent do not take kindly to 
enforced immobilization in the recumbent position. 

The prognosis in the aged in regard to union and subsequent func- 
tion is an entirely different problem. Impaction of fragments is the 
rule in these cases, particularly in fractures occurring in the outer half 
of the neck. In the aged this impaction should seldom be broken up to 
obtain more satisfactory position of fragments. In these patients 
anatomical results may be imperfect, but aside from a moderate degree 
of shortening and an irregular period of discomfort and pain, the 
patients should be able to get about with a slight limp after a period of 
several weeks, or at the worst may be obliged to use a cane for partial 
support. Fractures occurring in the inner half of the neck are more 
liable to be unimpacted than those of the outer half. In the unim- 
pacted cases of the inner half of the neck, bony union is the exception; 
fibrous union, pseudo-arthrosis or complete atrophy of the inner half 
of the neck is perhaps the rule. In impacted cases of this region im- 
paction may be broken up by slight jarring, by the weight of the body, 
or by secondary necrosis. Unimpacted fractures of the outer half of 
the neck under appropriate treatment should result favorably in firm, 
bony union, with a small amount of shortening and loss of function. 



476 TREATISE OX FRACTURES 

Even when non-union occurs in unimpacted fractures of the neck, a 
fair amount of weight-bearing is possible and with the use of a cane a 
favorable degree of function is present. There are many fractures in 
middle life and earlier in which a proper restoration of the anatomical 
contour is desirable and obtainable to a very great degree. Union in 
good position is to be sought sometimes even by operative fixation. 

Treatment. — There are two considerations in the treatment of 
fractures of the neck of the femur — the patient and the fracture itself. 
Fractures, whether impacted or not. inducing a tendency in the patient 
to the development of hypostatic pneumonia, cardial degeneration, 
bed-sores, and even those that show no such untoward symptoms 
except an inability to remain constantly confined in bed. should be dis- 
regarded to a certain extent so far as its treatment opposes the health 
of the patient. Hence apparatus should be removed and the patient 
set up in bed or placed in a wheel-chair. In many instances, however, 
no such emergency arises even in the aged. 

In impacted fractures in the old, liable to break neck close to head, 
it is unwise to attempt forcible reduction to secure better position of 
the fragments. These cases should be handled as carefully as pos- 
sible, and if there are no contraindications the Datient should be placed 
upon a firm level mattress, the foot of the bed slightly elevated, and 
the leg immobilized either by sand-bags placed on both sides or by the 
application of a long external T-splint. If there is muscular twitch- 
ing, it is advisable to supplement this dressing by the application of 
a Buck traction apparatus with from three to six pounds fastened to 
the stirrup i Fig. 609). This weight steadies the part and often gives 
considerable comfort. This dressing should be used for from four to 
eight weeks. It may be removed at this time and a short spica of 
plaster-of-Paris perhaps applied from the waist to mid-thigh, and the 
patient allowed upon crutches. In the aged it is better to remove all 
apparatus at the end oi about five weeks and allow the patient to get 
up: at first sitting up in bed a short time daily, later resting in a chair, 
and at the end of about ten weeks walking with crutches. 

Exception to the above rule in the treatment of impacted fractures 
is in cases occurring in early childhood or middle age, which, if left un- 
corrected, may result in a deforming coxa vara with considerable sub- 
sequent deformity and loss of function. In these cases it is advisable, 
perhaps only after consultation with another surgeon, to correct the 
deformity under ether, place the part in extreme abduction and trac- 
tion, and while in this corrected position to apply a gypsum spica splint 
from chest to toes of the affected side after the method of Whitman. 

There are several methods of treatment for non-impacted fractures 
that may be used The usual one employed as a routine is Buck's 
traction apparatus with from twelve to thirty pounds* weight attached 



FRACTURES OF THE FEMUR 



477 



to the stirrup, elevation of the foot of the bed for counter-traction, 
and lateral support by sand-bags, boxes of bricks or T-splint. A long- 
external straight splint extending from the axilla to below the foot 
may be used instead of the sand-bags (Fig. 609). Ac times this may 
be supplemented by a posterior splint carefully padded, extending from 
the crease of the buttock to a point several inches above the heel. 

It is probably true that nearly all new fractures in those approach- 
ing old age are impacted or the fragments entangled by the breaking 
force. The non-entangled and non-impacted fractures seen in practice 
have often, it is believed, been made so by improper handling. 

A second form of dressing is the use of longitudinal traction with 
the thigh in marked abduction. The same form of apparatus as in 




Fig. 609. — Method of applying Buck's traction apparatus. Adhesive plaster spreader to keep 
pressure from the malleoli, a padded posterior splint to keep the heel from the bed. This dressing 
should be supplemented by a Liston or T-splint or by sand-bags to steady extremity. Should have pad- 
ding to protect malleoli from pressure between skin of ankle and traction straps. By greatly elevating 
pulley and changing direction of pull, traction may be made in line of upper fragment if it be elevated 
and rotated outwards. 

the method given above may be used except that the external or 
Liston splint should not reach above the level of the trochanter. 

A third form, and this is of especial use in tiie young and the 
middle aged who stand immobilization well, is the method of abduc- 
tion to full normal extent devised and perfected by Whitman. He 
claims that the abduction method is based upon the anatomical con- 
struction of the joint, that its typical application implies the restora- 
tion of an approximately normal contour of the bone, which he believes 
is possible in the great majority of cervical fractures of the femur. 
Whitman thinks it the only safe and practicable means of correcting 



47' 



TREATISE OX FRACTURES 



deformity of the uncomplicated or so-called non-impacted type. The 
patient, usually anaesthetized, is lifted to a pelvic support, preferably 
furnished with a perineal bar for counter-pressure, and the extended 
limbs are supported by assistants. The assistant holding the unin- 
jured limb abducts it to the normal limit, in order that it may serve as 
a guide and incidentally to fix the pelvis. The injured limb is first 
flexed and rotated sufficiently to disengage soft parts that may be 
interposed between fragments. It is then completely extended, and the 
assistant, by direct manual traction, overcomes the shortening, as dem- 
onstrated by measurement and by the relation of the trochanter to 
Xelaton's line, at the same time correcting the outward rotation. Still 
maintaining steady traction, he then abducts the limb to correspond 
with its fellow, the operator meanwhile supporting the joint and lifting 







%p 'Sytm mm 



Fig. 6 io. — Principles to be considered in Whitman's abduction method for the treatment of 
fractures of the neck of the femur. (.-1) Normal range of abduction depends upon the angle of the neck 
with the shaft of the femur (i) ; the tension of the capsule (2) ; and the range of motion possible between 
the great trochanter and the superior run of the acetabulum (3 ) . (B) The usual displacement in fractures 
of the femoral neck. The outer fragment is pulled upward and backward by muscular pull (1) and by 
gravity. (C) Full abduction relaxes muscular tension (1), secures ligamentous tension of capsule (2). 
and forces the inner end of the outer fragment into place by the leverage action of the great trochanter 
against the superior rim of the acetabulum (3). (D) A form of impaction (1) which is broken up and 
reduction of fragments obtained by full abduction. (£) A form of incomplete fracture (1) which is 
corrected by full abduction of the limb. (Modified after R. Whitman.) 

the thigh upward. The pelvis should now be level and the extended 
limbs in exact correspondence in every j>articular. A plaster-of-Paris 
spica is applied from the axilla to the toes. This should be carefully 
adjusted about the pelvis and trochanter. It should completely cover 
the buttock and be heavily reinforced beneath the point and thigh, thai 
it may l>e unyielding to pressure and tberefore effective as a posterior 
splint to hold the limb at its proper plane. This method aims at re- 
ducing the fragments and holding them in anatomical position until 
consolidation occurs i Figs. 610-613 >. 

Another form of treatment that has met with considerable success, 
especially by its originators, is the Ruth-Maxwell method. This con- 
sist- in flexing the thigh at a right angle with the trunk to relax the 
psoas and iliacus muscles, and forcibly correcting the upward and 
backward displacement while in this position. After such correction. 



FRACTURES OF THE FEMUR 479 

continuous longitudinal and lateral traction is applied, the former by a 
Buck extension apparatus, using from fifteen to twenty pounds of 
weight, and the latter by passing about the thigh on the anterior in- 
ternal and posterior aspects padded binder's board, and over this a 
lateral traction apparatus with pulley and weight, pulling outward and 
upward so as to raise the upper end of the shaft and trochanter to its 
normal position. Four to eight pounds of weight should be used for 
lateral traction. Counter-traction is obtained by raising the foot of the 
bed six to ten inches and the side of the bed corresponding to the 
injured limb two to four inches. This method has many advantages 




Fig. 6ii. — -The elevation of the head of the bed (25 ) to provide a semi-reclining posture and thus 
to lessen the danger of thoracic congestion and to improve the nutrition of the injured part. (Whit- 
man, in Annals of Surgery.) 

and is probably better than the simple Buck longitudinal traction 
method and as efficient and less troublesome than the Whitman ab- 
duction method. 

Cotton has recommended operative impaction in some fractures 
of the femoral neck, without impaction from the injury. He strikes 
the trochanter with a mallet, thus causing locking of the fragments 
and encouraging union. This obviates to some extent the probability 
of disability that may arise if non-union should occur despite the 
usual treatment in the aged. 

In a few cases open operation and nailing of the fragments will be 
required. The cases calling for this procedure are those of non-union 



480 



TREATISE ON FRACTURES 



occurring in the young and middle-aged, robust individuals. In these 
cases either a nail or a fresh bone peg taken from the crest of the 
tibia may be used (Albee's method) ; whichever method is used, 
immobilization should be obtained by the use of a gypsum spica. 

After-Results. — Failure of union does not of itself mean entire loss 
of function. In many cases impaction has occurred at the time of 




Fie. 612. — The plaster spica holding the limb at the limit of normal abduction, illustrating the adjust- 
ment to the pelvis and to the hip. (Whitman, in Annals of Surgery.) 




fracture; and a large percentage of patients recover with fair ana- 
tomical and functional results. The report of the Committee on Treat- 
ment of Simple Fractures of the British Medical Association shows 
the following results obtained in fractures of the neck of the femur : 

Number of cases, qt ; anatomical results, good, 18, moderate, 18, 
bad 39; functional results, good, 24, moderate, 28, and bad, 39. Per- 



FRACTURES OF THE FEMUR 481 

centage of good anatomical and good functional results 16.4; percent- 
age of moderate or bad anatomical with good functional results 9.8 
per cent. Average duration of incapacitation (non-operative) under 
fifteen years, 7 cases traced, average number of weeks of incapacita- 
tion, 26.5; over fifteen years, 65 cases traced, average number of 
weeks of incapacitation, 53.2 These results are probably much less 
satisfactory than those usually obtained in American surgical practice, 
when the surgeon himself takes care of the patients and inspects them 
frequently. 

Separation of the Upper Femoral Epiphysis in Childhood. — Separa- 
tion of the epiphysis occurs in childhood, and is considered by some 
authorities to be a rather rare injury. During the past fifteen 
years, however, articles have been written by many surgeons, notably 
Hoffa, Hofmeister and Whitman, which prove conclusively the com- 
parative frequency of this injury. By some it is considered a true epi- 
physeal separation and by others a fracture of the neck of the femur 
close to the head. Often the lesion has been overlooked at the time of 
injury, and attention only called to it when there has developed, as a 
result of the injury and the too early weight-bearing on the part, a 
traumatic coxa vara. Sprengel, who first called the condition trau- 
matic coxa vara, and Hoffa consider the lesion to consist of a complete 
or incomplete separation of the epiphysis of the head, while Whitman 
maintains that the traumatic coxa vara usually is the result of a fracture 
of the neck of the femur. Radiographic examination shows generally 
either a true fracture of the neck near the head or a separation of the 
epiphysis of the head with a portion of the diaphysis of the neck 
attached. The fracture or the epiphyseal separation is usually incom- 
plete in character. The condition ma)' be observed up to the sixteenth 
year, but the majority of cases occur from the eighth to the twelfth 
year. 

Etiology. — The lesion occurs after direct injury to the hip. 

Symptoms. — The patient, after being confined to bed, perhaps only 
for a few days, gets up and walks about with a little lameness but not 
enough to suggest to the parents grave injury to the hip. This is 
accounted for by the fact that the lesion is incomplete, or when com- 
plete, firm impaction is present. Recovery takes place with a slight 
limp which fails to disappear, and later it is noticed that there is appre- 
ciable shortening of the femur, confined to the neck. As time goes on 
greater bending of the neck of the femur occurs, so that slight dis- 
ability is replaced by marked disability. There is now added promi- 
nence of the great trochanter, slight eversion, marked limitations of 
abduction, and slight pain. 

When these cases are seen shortly after injury and the possibility 
of grave injury recognized, the symptoms present will depend upon 
31 



482 TREATISE ON FRACTURES 

whether the fracture or separation is complete or incomplete. The 
differentiation between pure epiphyseal separation or fracture of the 
neck close to the head can only be made by radiogram. 

Diagnosis. — Fracture in or near the epiphyseal line is commonly 
the result of violence, such as a blow upon the hip or a fall upon the 
trochanter, a fall upon the feet, or while jumping with marked outward 
rotation of the lower limb. The early symptoms are shortening, out- 
ward rotation of the thigh, prominence of the trochanter; if the frac- 
ture or separation is complete, there may be harsh or soft crepitus, 
depending upon the lesion present. In Scarpa's triangle there may be 
felt a swelling corresponding to the upper end of the displaced lower 
fragment. 

The condition should not be confused with tuberculosis of the hip- 
joint in childhood, which it closely simulates; and it should also be 
diagnosed from the coxa vara due to softening of the neck of the 
femur, the result of deficiency in lime salts. 

In traumatic coxa vara the great trochanter is always above the 
Roser-Nelaton line ; this occurs in tuberculosis of the hip-joint only 
when the disease is far advanced and diagnosis is unmistakable. A 
radiographic examination will clear up the diagnosis. 

Treatment. — Treatment depends entirely upon whether the condi- 
tion is recognized at the time of injury or not until a resultant coxa 
vara is present. 

In recent fractures that are incomplete and in which deformity is 
present, the patient should be anesthetized, reduction made, and im- 
mobilization in the abducted position obtained by the use of the gypsum 
spica bandage as advocated by Whitman (Figs. 610-613). In com- 
plete fractures the treatment should be the same. After application 
of the plaster spica a radiogram will show whether reduction is satis- 
factory. In those cases in which reduction cannot be satisfactorily 
accomplished or maintained, open operation, with bone pegging if 
necessary, is recommended. Immobilization should be maintained for 
eight weeks, after which a suitable hip-splint should be worn for six 
months to a year. 

In those old cases in which the condition is only recognized after 
coxa vara is pronounced and union is firm the line of treatment should 
be quite different. If the lesion is seen within a few months after 
injury and the surgeon believes that something ma}- be gained by heavy 
traction, this may be used for a time in the hope of correcting the con- 
dition because union is not firm. When the diagnosis is made later and 
the condition of bent bone is marked and bony, osteotomy of the neck 
or in the subtrochanteric region should be performed and immobiliza- 
tion obtained by a plaster spica for eight to ten weeks, after which time 
a hip-splint should be used for six to nine months. 



FRACTURES OF THE FEMUR 483 

Fractures Through the Trochanters. — Under this class may be 
grouped the fractures involving the region of the trochanters (Figs. 
614-617). As a rule the fracture line is irregular and runs through 
the great trochanter, splitting it through the intertrochanteric line to 
a point above the lesser trochanter. In a few instances the latter will 
be found split in two or separately detached, or the fracture line may 
be spiral in character so that the upper fragment extends downward 
and consists of a pointed piece of bone, a part of the shaft: As a rule 
moderate comminution is present. These fractures should be separated 
from those occurring at the base of the neck and from those of the sub- 
trochanteric region; the differentiation from the latter consists in the 
fact that rarely does the small trochanter form a part of the upper 
fragment. The clinical difference of this last form of fracture (sub- 
trochanteric) is the fact that the action of the psoas and iliacus muscles 
tends to tilt the upper fragment upward when the fracture line is below 
the lesser trochanter. Formerly this form of fracture was considered 
rather rare, but from a study of radiograms its comparative frequency 
is manifest. 

Etiology. — This fracture is observed frequently in middle adult 
and early late life, the result of either a direct fall upon the tro- 
chanteric region or more commonly a fall in which the extremity is 
in marked adduction. The lesion sometimes partakes of the nature 
of a torsion fracture. In torsion fractures the line of fracture is 
through the great trochanter and intertrochanteric line ; and either the 
lesser trochanter is split into two fragments or it is separately detached 
by the action of the psoas and iliacus muscles. 

Symptoms. — The symptoms of fractures through the trochanters 
are prominence of the great trochanter, marked thickening in the re- 
gion of the trochanters, complete disability, shortening of the limb, 
eversion due to muscular relaxation, the weight of the limb and lack 
of control, and slight or absent impaction of fragments ; rotation of the 
limb shows rotation about the centre of the shaft of the femur and 
great trochanter, pain, tenderness on pressure, particularly over the 
region of the great trochanter and upper part of the shaft. Crepitus 
may be present in the absence of impaction upon rotation of the shaft 
of the femur combined with traction. 

Prognosis. — Fractures through the trochanters are extra-articular, 
and are usually followed by firm union, with considerable thickening 
from excessive callus in the trochanteric region, and a moderate degree 
of shortening. Some limitation of the normal range of motion is gen- 
erally permanent, and the patient recovers with a slight limp and has 
at certain times considerable permanent pain over the trochanteric 
region and down the outside of the thigh. Under careful treatment 
permanent eversion should seldom result. 



484 TREATISE ON FRACTURES 

Fig. 614. Fig. 615. 




Figs. 614, 61s. 616, and 6l7- — Fractures of the femur through the trochanters. 

Treatment. — As union of fragments occurs in this region, the 
question of impaction or non-impaction is not so important as in 



FRACTURES OF THE FEMUR 



485 



fracture of the neck of the femur. The majority of these fractures 
will be found to be but lightly impacted or quite unimpacted. Unless 
there is some marked contraindication, such as the patient's age, all of 
these fractures should be treated as unimpacted fractures. It is prob- 
able that anaesthesia generally should be used for reduction; this is to 
be accomplished by longitudinal traction in the abducted position and 
counter-traction by a strap around the perineum. All eversion and 
shortening should be corrected and parts placed permanently in the 
abducted position, after the Whitman method, in a gypsum spica. If 
for any reason this is not considered feasible, a Buck traction apparatus 




Figs. 618 and 619. — Fractures of the great trochan 



with from 15 to 25 pounds of weight should be applied with the limb 
in the abducted position, and an external axillo-tarscd and perhaps a 
posterior splint. The foot of the bed should be raised and on the 
affected side the bed should be higher than on the other side of the 
patient. A heavy moulded gypsum splint from axilla to ankle is better 
than the wooden splints. After four to six weeks a plaster spica may 
be applied and a few weeks later the use of crutches may be permitted 
if the well foot wears a high sole shoe. The weight-bearing of walking 
should not be begun for at least three or four months. 



TREATISE OX FRACTURES 



Fracture of the Great Trochanter, or Separation of the Apophysis. — 
Isolated fracture of the great trochanter (Figs. 618-619) is a very rare 
injury. In conjunction with fracture at the base of the neck or 
through the intertrochanteric line it is occasionally seen. The apophysis 
unites with the diaphysis of the bone at about the eighteenth year. 

Etiology. — Fracture of the great trochanter, or separation of this 
apophysis, is the result of direct violence or of muscular action. When 
the result of direct violence, there may be comminution. When 
the result of muscular action, it partakes of the nature of a tearing 
off of the cortex of the trochanter, while the same form of injury 
before the time of union of the apo- 
physis with the diaphysis will result 
in a complete separation of the apo- 
physis. The amount of displacement 
is dependent upon the periosteal cover- 
ing of the trochanter. 

Symptoms. — At first there may be 
only the symptoms usually associated 
with contusion. There is localized 
pain and tenderness on pressure, and 
on palpation it may be possible to dis- 
tinguish the movable fragment. Dis- 
placement of the fragment upward 
and backward by the action of the 
gluteus medius and minimus muscles 
( Fig. 620) is present, when the mus- 
cular attachments are torn from the 
diaphysis of the bone ; this displace- 
ment of the upper fragment may be as 
much as several inches. In the absence 
of localized swelling, flattening over 
the trochanter will be noted. Crep- 
pto^ ^SSS£faS^^Srt itus ma y at times be obtained by 
l r n °d c ^Tw„re^ h \ n SMK« fl exion. abduction, and outward rota- 

medius and minimus muscles. 




tion of the thigh and by pressing the 
fragments together. Primarily, palpation of the fragment and crep- 
itus are not obtainable on account of the localized pain and mus- 
cular spasm present. The thigh is generally held flexed and rotated 
inward, active motion is painful, abduction is limited or impossible, 
and shortening of the limb seen in cervical or shaft fractures is absent. 

Prognosis. — Without operative interference, union is generally 
fibrous in character, although future functional results are good. 

Treatment. — The non-operative treatment of fixation is a plaster 
spica in the abducted flexed position with the thigh rotated outward. 



FRACTURES OF THE FEMUR 487 

If radiographic examination shows approximation of fragments is not 
good by this method, open operation with direct fixation of the frag- 
ment by a nail should give good results. 

Fracture of the Lesser Trochanter. — Isolated fractures of the 
small trochanter are extremely rare. It is most frequently seen in 
conjunction with fractures through the trochanteric region. Isolated 
cases have been reported by several authors, and in them the condition 
has been recognized either by radiograms or has been confirmed by- 
autopsy. 

Etiology. — Of the reported cases the majority were observed in 
boys of seventeen years or younger, and were the result of muscular 
action in running or in avoiding a fall. Three cases were in men 
beyond middle life, in which the injury was due to muscular pull in 
falling. In one case the patient was run over by an omnibus. The 
lesion consisted of a tearing off of the lesser trochanter, and in two of 
the cases a portion of the shaft was attached to the fragment. The 
injury is due to the pull of the psoas and iliacus muscles. 

Symptoms. — The symptoms of fracture of the small trochanter are 
local pain and tenderness on pressure, which are increased by attempts 
at active flexion or passive extension of the hip-joint. In some of the 
reported cases the patients were able to walk; various degrees of 
eversion were present. Ecchymosis on the inside of the thigh appear- 
ing after twenty-four hours, together with swelling, are usually 
present. A positive diagnosis of the condition can only be made by 
radiogram. 

Treatment. — This should consist in immobilization in a plaster-of- 
Paris spica with flexion at the hip-joint. Union should occur in from 
six to eight weeks and may be fibrous in character. 

Fractures of the Subtrochanteric Region. — Fracture of the femur 
in the subtrochanter region (Figs. 621-622) are relatively frequent. 
Three varieties of fracture are seen in this region: the transverse, the 
oblique, and the spiral. 

Etiology. — Fractures below the trochanter are the result of either 
direct violence or indirect force. When resulting from direct violence 
the fracture line is apt to be transverse, while those occurring from 
indirect violence are either oblique or spiral in character. 

Symptoms. — Fractures of this region are unimpacted. The symp- 
toms are absolute disability, shortening, which is often marked, due to 
angularity of fragments and over-riding. Shortening is not marked 
in the transverse variety of fracture. There is marked outward rota- 
tion of the thigh and leg, due to gravity and lack of bony continuity, 
and free mobility of the lower fragment. Rotation of the shaft does 
not show corresponding rotation of the trochanter. Crepitus may be 
elicited when the line of fracture is transverse, as in this instance dis- 



488 



TREATISE OX FRACTURES 



placement of fragments is not great, but it is difficult to obtain in the 
oblique and spiral forms of fracture on account of the over-riding dis- 
placement of fragments and the interposition of soft parts. Deformity 
is generally marked, and consists of flexion with outward rotation of 
the upper fragment, due to the pull of the psoas and iliacus muscles 
upon the upper fragment, and abduction from action of the gluteus 
medius and minimus muscles upon the same fragment. In addition 
to these symptoms there is pain, localized tenderness, swelling, and 
ecchymosis ; and sometimes the sharp point of the lower end of the 
upper fragment may be felt on the anterior surface of the thigh. Oc- 
casionally puncture of the skin is threatened or is actually produced by 

Fig. 621. Fig. 622. 




Figs. 621 and 622. — Subtrochanteric fractures of the femur. 

this sharp fragment. The exact variety of fracture and position of 
fragments may be determinable only by radiogram. 

Prognosis. — Union takes place in the transverse fractures when 
there is little or no displacement of fragments with little or no de- 
formity. In a considerable* proportion of instances, however, the 
difficulty of maintaining reduction and accurate approximation of 
fragments results in some over-riding of fragments, with consequent 
shortening and anterior and external angular deformity. These de- 
fects may be largely due to inefficient or careless supervision of the 
treatment. 

Treatment. — The problem of treatment of fractures in this region 
is often very trying. Reduction as a rule can be readily accomplished. 



FRACTURES OF THE FEMUR 



489 



but the difficulty of maintaining reduction taxes the ingenuity of the 
surgeon and calls for careful observation of the fracture at all times. 
In cases in which there is little if any flexion or abduction of the upper 
fragment, apposition of fragments may be maintained by the use of 
Buck's traction apparatus, using fifteen to twenty pounds of weight 
with the hip moderately flexed and the knee extended, a padded pos- 
terior splint from the upper end of the thigh to a point above the 
heel, and a long external splint from the axilla to below the foot; 
and elevation of the foot of the bed for a distance of ten inches. If 
there is a tendency toward abduction of the lower end of the upper 



rrgl 




Fig. 623. — Modified Zuppinger's apparatus for treatment of fractures in the subtrochanteric 
region. Traction is obtained through an adhesive plaster dressing applied with the hip- and knee- 
joints flexed. Coaptation splints preserve to a great extent lateral alignment of the fragments. Suf- 
ficient weight should be used to correct overriding of fragments. 

fragment, this displacement may be overcome by the use of a pad be- 
tween the external splint and the lower end of the upper fragment, by 
traction in the abducted position, or by the use of a plaster spica with 
traction, applied with the limb in a position of abduction. The long 
splint with a pad is probably unwise in most cases, unless the fragments 
can be successfully locked at the time of reduction. Anaesthesia is 
desirable inmost fractures of the shaft, both for a correct understanding 
of the injury and to permit proper reduction. 

In the presence of more marked flexion deformity of the lower end 
of the upper fragment, several procedures may be adopted. The lower 
fragment must be brought in line with the upper fragment. This may 



490 TREATISE ON FRACTURES 

Fig. 624. Fig. 625. 




Fics. 62.;, - 1 fracture of the upper third of the shaft of the femur 



FRACTURES OF THE FEMUR 



491 



•a o 

3™ 






\ 






492 



TREATISE OX FRACTURES 




Fn;s. 6jo. 631, (132 



-Types of fracture of the lower third cf the shaft of the femur. 



be accomplished in children by vertical extension ; adults may not take 
kindly to this form of extension. In adults, anatomical apposition may 
be maintained by the use of a plaster spica from the lower chest level 
to the knee, applied with the thigh in a position of flexion and the use 



FRACTURES OF THE FEMUR 



493 






494 TREATISE ON FRACTURES 

of traction from the thigh. The same position of fragments may be 
obtained, though less satisfactorily, by the use of the Smith or Hodgen 
splint or the double-inclined plane. In some fractures here at times lon- 
gitudinal traction, posterior splint, and a long external splint com- 
bined with a bag of shot or sand over the lower end of the upper 
fragment may give satisfactory apposition, although this method re- 
quires considerable attention and is not strongly advocated. If satis- 
factory position cannot be obtained by one of these methods, operation 
and direct fixation of the fragments by a steel plate is advocated. 
These fractures are especially adapted to the plate fixation method be- 
cause of the difficulty of maintaining coaptation by external apparatus, 
when displacement is marked. 




Fig. 637.— Type of fracture of shaft of femur occurring in childhood. 

Whatever method of treatment is used, it should be continued, if 
satisfactory, until firm union has taken place; weight-bearing should 
not be attempted for at least twenty to thirty weeks after the time of 
injury. 

Fractures of the Shaft of the Femur 

Fractures of the shaft of the femur include those occurring below 
the subtrochanteric region and above the supracondylar site. They are 
most commonly met with during active adult life and in the male sex, 
and usually affect the middle, occasionally the upper and rarely the lower 
third of the bone. Of 55 fractures of the shaft of the femur observed 
by Plagemann, the upper third was involved 9 times, the middle third 40 
times, and the lower third 6 times The fracture line was irregularly 



FRACTURES OF THE FEMUR 



485 



transverse 28 times, spiral 13 times, oblique 8 times, and oblique with a 
third fragment 6 times. In this series, therefore, one-fifth of all 
fractures of the shaft are spiral in character. 

Etiology. — Fractures of the shaft of the femur are, as are other 
fractures in the shafts of long bones, the result of direct or indirect 
violence or muscular action. Fractures from direct violence are most 
frequently found in the lower third of the bone, and are due to crush- 
ing injuries, such as from falling walls or weights and being run over 
by vehicles. Fractures by direct violence occur most frequently in the 
middle and occasionally in the upper FlG 638 

thirds of the bone, as in a fail upon 
the feet. Muscular action is found 
as a cause in fractures in the upper 
and occasionally in the middle 
thirds of the femur, which result 
from a sudden twist of the body 
and upper part of the thigh with 
the foot in a fixed position. 

Varieties. — The line of break 
follows certain definite lines, de- 
pending upon the position of the 
fracture and the nature of the 
violence (Figs. 624-638). Frac- 
tures by direct violence are usually 
transverse; at times there is a three- 
cornered piece of bone broken off at 
the point distal to the direction of 
force. Fractures by indirect vio- 
lence are generally oblique, while 
fractures by muscular action are 
spiral in character; here the frag- 
ments are often very sharp and 
oblique, and at times there is a 
rhomboidal portion of bone de- 
tached at a point of fracture. Oblique and spiral fractures show a tend- 
ency to be open, due to the piercing of the soft parts and skin by a sharp 
fragment ; fractures by direct violence are more apt to be comminuted as 
well as open, and not infrequently are attended with considerable 
destruction of overlaying soft parts. Incomplete fractures here are 
extremely rare. 

Symptoms. — The symptoms of complete fracture of the shaft of 
the femur are loss of voluntary motion, or if any motion is present 
attempts to lift the leg from the bed show angular deformity at the 
seat of fracture. There are present deformity, abnormal mobility 




Comminuted fracture of shaft of femur. 



496 TREATISE ON FRACTURES 

(Fig. 639) and crepitus at the site of fracture, eversion of the knee, 
leg and foot, and shortening of the limb. The shortening is due to 
the obliquity of the fracture line permitting over-riding of the frag- 
ments from the muscular pull. There is swelling from infiltration of 
soft parts beneath the deep fascia about the seat of fracture. Short- 
ening may be overcome by strong, steady traction and counter-traction, 
and its presence may be estimated by measurement of both extremities 
from the anterior superior spine of the ilium to the internal malleolus 
or to the tibial tubercle, or from the umbilicus or ensiform cartilage to 
the malleoli. Shortening varies from one to five or six inches. In 
making these measurements the patient should be placed upon a flat, 
firm mattress and the extremities should be at right angles to a line 
drawn through the two anterior superior spines of the ilium. The 
asymmetry in length of normal bones must not be forgotten in estimat- 
ing shortening in fractures. In transverse fractures there may be 




Fig. 639. — Method of determining abnormal mobility and crepitus in fracture of the shaft of the femur. 

little or no shortening because of the absence of marked displacement 
of fragments or of entanglement or impaction of fragments. Dis- 
placement of fragments and angular deformity are. however, the rule 
in complete, unimpacted fractures. Factors acting in the production 
of displacement are the direction of the fracturing force, the curve of 
the bone, and the traction of attached muscles. Rotation of the lower 
fragment externally is the rule in all fractures of the shaft and is due 
to the weight of the limb ( Figs. 640-646). 

Typical Displacement in the Different Regions. — In fractures of 
the upper third of the shaft (Fig. 647) the lower end of the upper 
fragment tends to be displaced forward and rotated outward. This 
deformity is due to the action of the psoas and iliacus, and the gluteus 
medius and minimus muscles, while the upper end of the lower frag- 
ment is drawn upward, inward and posteriorly by the action of the 



FRACTURES OF THE FEMUR 



497 



adductor and flexor muscles. Angular displacement is thereby pro- 
duced. Displacement, however, may be absent in transverse fractures 
and in those close to the trochanters. In fractures of the middle third 
(Figs. 648 and 649) close to the upper third, the same type of dis- 
placement of fragments may occur as in fractures of the upper third. 
When, however the line of fracture is below the attachment of the 




Fig. 540. — Femur; fracture through trochanters; union has taken place with shortening, angulation, 
and outward rotation of the lower fragment. (Wister Institute of Anatomy.) 

Fig. 641. — Femur, right; fracture of the upper shaft. Union with anterior angular deformity. 
The fracture occurred at the junction of the middle and upper thirds, and was probably nearly trans- 
verse. The psoas magnus and internal iliac muscles have elevated the end of the upper fragment 55 
degrees so that the bones have united with great anterior deformity. The lower fragment has passed 
-upward and backward. There is no outward quotation of the lower fragment. (Mutter Museum, 
No. 1397.035-) 

Fig. 642. — Femur, right; fracture of the neck, trochanter major and shaft; recent. The injury 
was a severe one in which, while the trochanter was fractured by direct violence, the shaft was prob- 
ably broken by twist leverage being obtained at the knee. The upper fragment consists of the head, 
neck, trochanters and a portion of the outer shaft, terminating in a point. Passing from this point 
13 cm. below the great trochanter we trace a line passing spirally upward and backward. Looking 
on the external surface of the great trochanter, a Y-shaped fracture is seen. (Mutter Museum, No. 
1397-031.) 

Fig. 643. — Femur, right: transverse fracture of middle shaft. Recent union. The fracture 
occurred just above the middle. The lower fragment passed upward to the inner side and slightiv 
backward. The shortening amounts to 5 cm. The lower fragment has rotated outward 20 degrees. 
(.Mutter Museum, Xo. 1397.055.) 



short and long adductor muscles, the lower end of the upper fragment 
is drawn inward and forward and the lower fragment is displaced 
upward, outward, and backward. In fractures of the lower third the 
32 



498 



TREATISE ON FRACTURES 



lower end of the upper fragment is drawn inward and forward by the 
adductors and extensor muscles, and the lower fragment upward and 
backward by the flexor muscles. At times the upper end of the lower 
fragment is also rotated backward by the action of the gastrocnemius 
muscle. 

Other symptoms present are pain, localized tenderness on pressure, 
swelling, ecchymosis, and muscular spasm. Early effusion into the 




FlG. 644. — Femur, left; fracture of the middle shaft. There is great shortening and anterior angular 
deformity. Sharp prominence of the upper fragment. (Mutter Museum, No. 1397.058.) 

Fig. 645. — Femur, left; fracture of the lower shaft; union with deformity. The fracture occurred 
at the junction of the middle and lower third and was probably nearly transverse. The lower fragment 
points inward 10 degrees but has not rotated. It has passed upward and backward and has united 
firmly. The upper fragment presents a prominence anteriorly while the lower fragment projects on 
the outer side. The inner side of the line of junction is grooved. (Mutter Museum, No. 1397.071.) 

Fig. 6 ]6. — Femur; fracture of the shaft, junction of the middle and lower thirds. Union with 
marked deformity, consisting of overriding and inward rotation of the lower fragment, and the forma- 
tion of exuberant callus as a spur from the lower end of the upper fragment. (Wister Institute of 
Anatomy.) 

knee-joint is often present in fractures of the lower third of the shaft. 
Complications. — In fractures of the upper and middle thirds of the 
shaft, complications are rare. In fractures of the lower third they arc 
occasionally present. Puncture of the muscles and skin by a sharp- 
pointed fragment may cause the injury to be an open one. The pre- 



FRACTURES OP THE FEMUR 



499 



patellar bursa may at times be penetrated. Vessel injury, such as rup- 
ture or compression of the femoral artery or vein with resulting hemor- 
rhage, aneurism, or gangrene, may happen. Nerve injury is extremely 
rare from shaft fractures, but occurs to the popliteal or peroneal 
nerves in condylar or supra- ~~ 
condylar breaks. 

Prognosis. — The p rog- 
nosis in fractures of the shaft 
of the femur is, as a rule, 
favorable. Union occurs or- 
dinarily in six to ten weeks, 
after which time patients may 
be allowed up on crutches, 
provided the line of fracture is 
supported by a plaster spica 
dressing from waist to below 
knee, or by a suitable brace. 
The weight-bearing in walk- 
ing should be prohibited for 
four or five months from the 
time of injury. The arching 
forward of the shaft of the 
normal femur should not be 
forgotten in reconstructing 
the bone after fracture. Lit- 
tle permanent shortening 
should follow well-treated 
fractures of the femur if per- 
fect anatomical apposition of 
fragments is obtained. This, 
as a rule, cannot be obtained 
by non-operative means, ex- 
cept in the most favorable 
cases. Such absolute recon- 
struction of the length of the 
bone is not extremely im- 
portant. Shortening is 
rule in oblique, spiral, com- 
minuted fractures and in fractures uniting in a position of over-riding 
or angulation. This may vary from a fraction of an inch to several 
inches. If, however, union is obtained with the fragments in good 
alignment, without rotary displacement, a shortening of even three- 
quarters to an inch will cause little limp in gait, and can be considered 
as a good functional result by non-operative means. A slight addition 




Fig. 647. — Drawing to show type of displacement 
which may occur in fractures of the upper third of the 
shaft of the femur. (Made after rdntgenogram, Fig. 
624.) The upper fragment is pulled upward, forward and 
outward by the action of the iliopsoas and gluteus medius 
i-Up and minimus, and the lower fragment is pulled upward 
Lllc and inward by the quadratus femoris, the biceps and 
adductor muscles. 



500 



TREATISE ON FRACTURES 



to the heel of the shoe or a pad of leather within the shoe under the 
patient's heel will correct the limp and prevent lateral spinal deviation. 
When these fractures are subjected to operative fixation, there 
should be no shortening angulation or rotary displacement, unless the 
fracture is comminuted or local necrosis of bone follows operation. 



Fig. 648. 


Fig. 649. 




,jR 




w 




IW 




'■J V 


^■r 


'.^.J,- 



Fig. 648.— Fracture of the middle of the shaft of the femur in childhood. Note overriding and angu- 

. lation pi fragments, and outward rotation of the lower fragment. 

Fig. 649. — Drawing to show the action of the thigh muscles in causing displacement of fragments. 

(Made after rontgenogram, Fig. 648.) 



Union as a rule is delayed by operative fixation. In stout people and 
in the aged the possibility of hypostatic pneumonia, bed-sores, and fat 
embolus should always be considered. 

Effusion into the knee-joint is usual in fractures of the lower third 
and is the result of the primary violence, the penetration of the joint 
cavity by sharp fragments of bone, or the extravasation of blood at the 



FRACTURES OF THE FEMUR 501 

time of fracture. It may occur shortly after the time of injury and 
may be serous or sanguineous in character. Another form of effusion 
is that seen when the patient begins to use the knee-joint after con- 
valescence. The effusion is the result of strain of use upon atrophied 
and quiescent structures about the joint. (Edema of the leg is due to 
change of position, muscular activity, or to partial venous or lymphatic 
obstruction at the seat of fracture. 

Muscular atrophy, the result of disuse, may persist for some time, 
while rigidity of the knee may be persistent, particularly in the aged 
and rheumatic. These sequels often may be averted if early passive 
and active movements and very careful massage are employed daily or 
two or three times a week from the beginning of treatment, following 
the advice of Lucas-Championniere. Hence the defect of prolonged 
absolute immobilization. 

Pseudo-arthrosis is occasionally seen as the result of over-riding 
of fragments, failure of reduction, interposition of soft parts, faulty 
immobilization of fragments, operative necrosis, and general systemic 
diseases. The most frequent cause of poor functional results are fail- 
ure of reduction, allowing shortening, angulation, rotary displacement, 
faulty immobilization, exuberant callus, muscular atrophy, stiffness of 
knee-joint and pseudo-arthrosis. 

Treatment. — In the treatment of fractures of the shaft of the 
femur the method of procedure will depend in a great measure upon 
the site and the line of fracture, the amount and direction of displace- 
ment of fragments, and the age of the patient. Operation and direct 
fixation of fragments usually give good results in fractures of the shaft 
of the femur, provided the operator be experienced and have a perfect 
aseptic technic. They overcome many of the difficulties attendant upon 
non-operative treatment in difficult cases. This is particularly the case 
in the fractures of the upper and lower thirds of the bone with marked 
displacement of fragments. In healthy adults, in whom operation 
is not contraindicated, this form of treatment would be the choice 
for fractures in which there is grave difficulty in reduction or in main- 
taining reduction by non-operative means. Unfortunately the depth 
of the femur and the strong muscles surrounding it make the operation 
a difficult one for the occasional operator, and greatly increase the risk 
of septic complications. 

In those cases in which good results reasonably may be expected 
by non-operative measures, the exact method of retaining the 
apposition of fragments will be selected according to the site of the 
fracture. In the majority of cases the reduction of fragments and 
the application of immobilizing apparatus should be performed under 
general anaesthesia. The omission of the anaesthesia has been the 
explanation of many bad anatomical results and has caused the ope- 



502 TREATISE ON FRACTURES 

rative fixation to obtain many advocates. The patient's bed should 
have a level, firm mattress, which should be additionally supported by 
several flat boards placed under it running across from the sides of 
the bed. A wire spring mattress, indeed any form of spring mattress, 
is an almost inexcusable error. 

In many fractures of the shaft, reduction may be accomplished 
readily by immediate traction and counter-traction, especially if gen- 
eral anaesthesia be used. This is particularly so in transverse and 
oblique fractures. The pelvis and upper part of the thigh should be 
held firmly by one assistant, while another makes prolonged and 
steady traction by grasping the foot and leg with both hands. The 
surgeon meanwhile endeavors to obtain complete reduction by manipu- 
lation. In fractures of the upper third or at the junction of the upper 
and middle thirds, it will often be necessary to elevate the leg and 
knee so as to bring the lower fragment in a line with the upper, which 
may be flexed and abducted by the iliopsoas and the gluteus medius 
and minimus muscles. In fracture of the lower third, flexion at the 
hip and knee with steady traction on the flexed leg will generally result 
in reduction. When there is impalement of the muscles upon the sharp 
end of a fragment they may be freed by rotation of the fragment. If 
not thus released, an incision may be required to accomplish this 
object. After the fracture has been reduced and the ends of the frag- 
ments engaged, so as to make the coaptation perfect or nearly so, an 
immobilizing dressing is to be applied while the patient is relaxed and 
free from spasm and pain by the anaesthetic. 

Various forms of immobilization apparatus may be used to main- 
tain proper reduction of fragments. The one that has the greatest field 
of usefulness is the modified Buck traction apparatus. It is very satis- 
factory in fractures of the middle third, of the upper third, when there 
is little tendency toward flexion and outward displacement of the lower 
end of the upper fragment, and in fractures of the lower third where 
the upper end of the lower fragment is not drawn backward. It is 
applied in the following manner : The leg and thigh are cleansed with 
soap and water, shaved, and bathed with alcohol and ether. After re- 
duction of the fracture, two strips of rubber adhesive plaster three 
inches in width and long enough to extend from a point four inches 
above the seat of fracture to six inches below the foot are smoothly 
applied along the middle of the internal and external surfaces of the 
leg and thigh from above the seat of fracture. The malleoli are pro- 
tected by several layers of a flannel bandage, and three circular strips 
of plaster one and one-half inches wide are applied circularly almost 
completely around the limb; one is placed two inches above the mal- 
leoli, one below the knee, and the third just below the seat of fracture. 
Instead of the three circular strips, reinforcement of the lateral strips 



FRACTURES OF THE FEMUR 



503 



may be secured by strips of plaster two inches in width applied diag- 
onally from two inches above the malleoli to the seat of fracture. 

Two ends of the longitudinal strips are secured to a spreader or stir- 
rup, made of wood three inches wide, four and a half to five inches 
long, and perforated at its centre by a hole for the traction rope (Fig. 
650) . The adhesive dressing is covered by a bandage from just above 
the malleoli to the level of the upper end of the lower fragment. The 
ends of the traction strips of plaster are then turned down over the 
inner layers of bandage, and the bandage carried upward almost to 
the hip. A posterior or ham splint of wood or metal, well padded, is 
placed posteriorly, extending from the upper level of the thigh to two 




Fig. 650. — Method of applying Buck's traction apparatus. Adhesive plaster, spreader to keep 
pressure from the malleoli, a padded posterior splint to keep the heel from the bed. This dressing 
should be supplemented by a Liston or T-splint or by sand-bags to steady the extremity. 



inches above the calcaneum, and is secured with three strips of ad- 
hesive plaster (Fig. 651). This splint is only occasionally needed if 
the bed is level and firm and a soft pillow is placed under the popliteal 
space. Coaptation splints to surround the thigh on the internal an- 
terior and external surfaces are applied and held in place by three 
strips of adhesive plaster or webbing straps. An internal splint is 
applied, from one inch below the perineum to one inch above the 
internal malleolus, and a long splint from the mid-chest region to 
a point two inches below the sole of the foot. These two splints 
are secured to the thigh and leg by webbing straps, and the external 
splint is held to the chest wall by a wide swathe, and a similar one 
is placed about the splint and pelvis (Fig. 652). In applying this 
apparatus care should be taken to see that the inner surface of the-first 



504 



TREATISE OX FRACTURES 



metatarsal, the middle of the patella, and the anterior superior spine 
of the ilium are in a straight line and the foot is not too much 
everted. After its application the patient may be placed on a Bradford 




Fig. 651. — Second stage of the modified Buck's traction apparatus. A cotton roller bandage 
has been applied from the malleoli to the lower third: the thigh is surrounded by several layers of 
sheet-wadding and coaptation splints have been applied to the thigh. Sometimes the coaptation 
splints may be omitted or a gypum-gauze contour trough substituted. If the fracture is reduced well, 
before applying the dressing, this is especially the case. 




Fig. 652. — The dressing is completed by an internal splint, a I.iston or T external splint, a bodv swathe 
to hold the upper end of the splint against the pelvis, and bed-blocks to elevate the foot of the bed. 

frame, the foot of the bed elevated eight inches or more, a pulley 
attached to the foot of the bed. over which is carried the rope, con- 
nected with the spreader. To the end of the rope from fifteen 



FRACTURES OF THE FEMUR 505 

to thirty-five pounds weight should be added for keeping up traction 
on the thigh muscles. Counter-traction is obtained by the weight of 
the patient; and if this is not sufficient perineal straps connected with 
the head of the bed may be used. A bed-cradle should be placed over 
the patient's legs to keep the weight of the bedclothing off the feet. 

This form of apparatus requires constant supervision. Care 
should be taken to see that traction is constant, that over-riding of 
fragments has not recurred, that outward or posterior angulation at 
the seat of fracture is prevented, and that inward or outward rotation 
of the leg and lower fragment is not present. This supervision is 
more likely to be maintained and deviations at the point of break dis- 
cerned if the internal lateral splint, the Bradford frame and the Liston 
external splint are omitted and boxes of bricks or good sand-bag sup- 
port used instead. This change is permissible in the opinion of one 
of the authors in many instances. The omission of these adjuncts 
permits the more frequent application of light massage and passive 
motion to the muscles and joints. These manipulations are believed 
to be valuable adjuncts to restoration of function. 

In ordinary fractures of the shafts of the femur, this modified 
Buck apparatus should be followed by a good result, and union should 
occur in from seven to nine weeks. The apparatus should then be 
removed and replaced by a plaster spica including the pelvis, thigh and 
part of leg, and the patient gradually allowed up on crutches with a 
high shoe on the well foot. Weight-bearing should not be allowed for 
three to five months from the time of injury. The time depends some- 
what upon the body weight of the patient and the type of fracture. 
A more comfortable form of ambulatory immobilization is some form 
of convalescent, but expensive, hip splint (see Fig. 659). 

In fractures of the upper third with the lower end of the upper 
fragment in a flexed position and in abducted rotation, it is often im- 
possible to maintain reduction by horizontal traction. It is then neces- 
sary to bring the lower fragment in line with the tilted upper one, 
maintain the two fragments in this position, and use traction to pre- 
vent over-riding of fragments (Fig. 623). This may be accomplished 
by traction applied to the thigh partially flexed at the hip and encased 
in a plaster-of-Paris spica, which includes the pelvis, thigh, leg, and 
foot. The gypsum case is applied with the thigh in flexion, with slight 
abduction and some outward rotation with the leg flexed about 45 
degrees on the thigh. This dressing is used for from at least four to 
six weeks ; after this time it may be replaced, if union and position are 
good, by a plaster spica in the extended position without traction. 
After ten weeks the patient may be allowed to be out of bed on 
crutches, and weight-bearing may be permitted at the end of four 
months. If for any reason it is not considered advisable to use this 



506 TREATISE OX FRACTURES 

form of apparatus, fair results may occasionally be obtained by the 
carefully watched double inclined plane with traction from the thigh, 
i ir the Smith or Hodgen anterior wire splint combining suspension 
with traction. Fractures in this region, if wisely treated, generally 
give fair functional results, but there is quite often some shortening 
and angulation unless they are treated by open operation. 

Fractures of the lower third of the femur are not all characterized 
by posterior displacement of the upper end of the lower fragment. In 
fractures without this posterior displacement of the lower fragment, 
good results may be obtained by the use of the already described Buck 
traction apparatus. 

Comminuted fractures of this region are best treated by the same 
dressing. When there is posterior displacement of the upper end of 
the lower fragment and it is found impossible to retain the fragments 
in good position, tenotomy of the Achilles tendon may be performed, 
if it is thought that the displacement is due to the pull of the gastroc- 
nemius muscle. Good position may also be obtained by the use of a 
plaster spica dressing including the pelvis, thigh, leg and foot, applied 
with the thigh and leg in a position of flexion, and the use of traction 
from the lower part of the thigh and by the use of traction applied 
with the hip- and knee-joints flexed (Fig. 623). In all adult cases 
the normal anterior convexity of the femur, marked in muscular sub- 
jects, should not be forgotten when applying support posteriorly. 

Robert Jones highly recommends the use of the Thomas knee splint 
for all fractures of the shaft of the femur. He is persuaded the fault 
lies not in the way the fracture is set in the first instance, but in the 
fact that the thigh muscles subsequently contract and produce too much 
movement of the fragments with over-riding and shortening. He be- 
lieves that if weight and pulley traction be used, as in Buck's method, 
the muscles of the thigh are suddenly relieved of tension every time 
the patient moves his body, and thereupon contract. In his opinion a 
rigid system of extension should be adopted, which results in muscles 
ceasing to resist in from twenty-four to forty-eight hours. His method 
is to fix the broken limb in a rigid apparatus from pelvis to foot, which 
gives traction and counter-traction; then the patient can be moved, 
lifted, and nursed without the slightest fear of muscular action tele- 
scoping the fragments. Tims starting pains are unknown and the 
alignment of the thigh is as nearly perfect as possible. A properly 
applied Bradford frame may meet Jones's requirements. 

The difficulties met in children in the treatment of fractures of the 
shaft of the femur arc the frequency with which dressings are soiled 
by urine and faeces, liability to excoriations, and the case with which 
dressings become displaced. Fracture dressings suitable for adults 
arc consequently not always available. These troubles may be obviated 




Fig. 655. 



Pigs. 653, 654. and 655-— Vertical extension for the treatment of fractures of the femur in 
children. Fig. 653: Adhesive plaster traction, overhead traction, weights and Bradford frame. 
Fig. 654: Cotton bandage applied from the malleoli to the lower thigh; thigh surrounded by sheet- 
wadding layers and by coaptation splints and straps. Swathe to hold patient still upon Bradford 

Fig. 655: Method of slowly decreasing the 



I - 



TREATISE ON FRACTURES 



and good anatomical and functional result obtained by the Bryant 
vertical traction method (Figs. 653-658). Adhesive plaster strips. 
an inch or more in width, are applied from the point of fracture to 

Fig. 656. 

■i 




. ?*"? , I ? S $ and 657. — Another method of vertical exte- method for fracture of the 

shaft of the femur, which may- bt jdults as well as children. 

one inch above the malleoli and continued two inches below the foot, 
where they are placed over a wooden perforated spreader three inches 
in length and about one inch in width. These strips are supplemented 



FRACTURES OF THE FEMUR 



509 



by three circular strips two inches in width, one at the seat of fracture, 
one below the knee, and the third one and a half inches above the 
malleoli, and by two one-inch straps applied diagonally from above 
the malleoli to the seat of fracture. This dressing is covered by a 
flannel bandage from above the malleoli to the upper limit of the thigh, 
and the entire thigh surrounded by coaptation splints held in place by 
three webbing straps applied at the two extremities and middle of the 
splint. A thin rope is passed through the hole in the spreader and 
through the pulley of the overhead traction gallows, and sufficient 
weight used to just lift the gluteal region of the affected side off of the 
bed. Traction should be in a vertical direction. The coaptation 




Fie. 658.— Christe 



sthod for treatment of fractures of the shaft of the fen 



splints are often unnecessary. The patient is then placed on a Brad- 
ford frame and held to it by a swathe including the chest and abdomen. 
The Bradford frame may often be omitted. This method of traction 
gives very satisfactory results in children up to ten or twelve years of 
age, and may be used for fractures of all parts of the shaft of the 
femur. Attention should be paid to the parts so as to prevent sagging 
of the leg and inward or outward rotation below the seat of fracture. 
Excoriations about the malleoli and buttocks should be avoided, and 
the coaptation splints should be readjusted from time to time. At the 
end of six to seven weeks the angle of traction may be slowly lowered, 
so that in the course of a week the horizontal position is attained, 
after which time a plaster spica including pelvis, thigh and leg, may 



510 



TREATISE OX FRACTURES 



l^e applied and the patient allowed on crutches. Weight-bearing may 
be started at the end of twelve to fourteen weeks. During late con- 
valescence an ambulatant hip splint should be vised (Fig. 659). 

Results. — The report of the Committee on Treatment of Simple 
Fractures of the British Medical Association shows the following re- 
sults : Xon-operative : upper third of femur in 3 cases, good anatomical 
and good functional results in 3 cases ; middle third 27 cases, good ana- 
tomical and good functional results in 2? 
cases : lower third. 2 cases, good anatomi- 
cal and good functional results in 1 case. 
Average duration of incapacitation, num- 
ber of cases in which period was stated in 
fractures of shaft or femur 196 cases, 
average number of weeks of incapacitation 
16.5 under fifteen years: over fifteen years, 
number of cases 179, number of weeks of 
incapacitation 33.6. and number of cases 
in which incapacitation was permanent 
21, — 1 1.7 per cent. The number of 
operative cases was so small that com- 
parison was not possible. A considera- 
tion of the good results of the upper 
middle and lower thirds according to 
age periods was as follows : upper third. 
under fifteen years, 95 per cent.; between 
sixteen and forty-five years 70 per cent., 
and over forty-five years 31 per cent.: 
middle third.' under fifteen years 97 per 
cent., sixteen to forty-five years 58 per 
cent., over forty-five years t,2 per cent. : 
ower third, under fifteen years 94 per 
cent., sixteen to forty-five years 68 per 
cent., and over fortv five vears 40 per cent. 
^dCSSer^fe^ Some statistics on this point from the Re- 

and the patient 




Fig. r, 5 o.— Convalesc. 
used in the treatment of 
femur when the patient 
Shou'd be used 



If 



^tZ^ZZr^eTl^nT^l port of the Committee of the American 
Se™«^vr^„TeS!u?f d A ^S Surgical Association will be found in 

encasement >s cheaper. Cbapters I aild II. 

It is the belief of one of the authors that British surgeons have 
obtained poorer results in the non-operative treatment of fractures 
than is the case where long immobilization is less the rule than in Great 
Britain. Prolonged immobilization is, he Ijelieves, a mistake in fracture 
treatment, as it prevents frequent examination and readjustment of 
fragments ; and tends to articular rigidity and muscular atrophy from 
which convalescence is slow. 



FRACTURES OF THE FEMUR 



511 



Fractures of the Lower End of the Femur 

Fractures of the lower end of the femur are of interest on account 
of their comparative rarity and the complications that may be present. 
The line of fracture may be in the shaft just above the condyles, the 
supracondylar fracture ; at the same time this line may connect with one 




Fig. 660. — Supracondylar fracture of femur. Note the posterior displacement of the upper end of 
the lower fragment. 
Fig. 661.— Drawing to show the pull exerted by the gastrocnemius muscle in producing posterior 
displacement of upper end of lower fragment. (Made after rontgenogram, Fig. 660.) The liability 
to injury of the popliteal vessels and nerve is shown. 

running down between the condyles, separating them, causing inter- 
condylar T- or Y-fracture. Either the internal or external condyles 
may alone be separated from the remaining portion of the bone, 
or there may be a complete separation of the lower epiphysis of the 




Fig. 662. — Comminuted supracondylar fracture of the femur. 
F:g. 663. — Comminuted supracondylar fracture of the femur. Note over-riding of fragments and 
callus formation. 
Fig. 664. Fig. ( 





Fig. 664. — Supracondylar fracture of the femur. Union with lateral, over-riding and rotary deformity. 

Fig. 663. — Comminuted supra-intracondylar fracture of the femur. Anteroposterior view. ^See 

Fig. 666.) 



FRACTURES OF THE FEMUR 



513 



femur. The last condition is only observed before the twentieth 
year. Another rare form of fracture is the separation of small cor- 
tical portions of bone from the surface of the internal or external 
condyle due to strain on the ligaments, the so-called " sprain- 
fracture." The most typical fractures are the oblique fractures of 
one or both condyles and the irregular T- or Y-fractures, in which 
the two condyles are separated from each other and from the shaft of 
the bone. 

Supracondylar and Intercondylar Fractures (Figs. 660-669). — 
Simple supracondylar fractures differ but little from low fractures 
of the lower third of the femur, except in the position of the line 

Fig. 666. Fig. 667. 




Fig. 666. — Comminuted supra-intracondylar fracture of the femur. Lateral view. (See Fig. 66s). 
Fig. 667. — Supracondylar fracture of the femur in a child aged 3 years. 

of fracture, and will not be here differentiated. When, however, they 
are associated with a split of the lower fragment by a fracture line 
running from the transverse line through the intercondylar notch, the 
clinical picture is entirely different. 

Etiology. — The cause of intercondylar fractures is severe violence, 
either direct or indirect, such as a blow upon the knee, a fall upon the 
knee from a height, or perhaps a violent impact with torsion trans- 
mitted from foot to femur. The mechanism of fracture is that the 
splitting of the lower fragment results from the wedge-like action of 
the lower end of the upper fragment separating the lower fragment 
into two or more parts and producing the typical T- or Y-shaped frac- 
ture. The line of fracture across the shaft is generally oblicme, though 
33 



514 



TREATISE OX FRACTURES 



at times transverse, and that of the lower fragment is more or less 
vertical and in an anteroposterior plane. Comminution of fragments 
may be present, and the lower end of the upper fragment may pierce 




lower shaft. Union with anterior deformity and short- 
the joint and was nearly transverse. The lower fragment 
passed backward, upward and to the outer side, and union has occurred in that position. (Mutter 
Museum, No. 1397.079.) 

Fig. 669. — Femur, left; comminuted intercondylar fracture. Union with deformity (plaster 
cast). The condyles are split so that the outer fragment is the smaller. The shaft was broken 
obliquely immediately above the condyles, from behind, downward and forward, the fragments com- 
pressing the condyles passing upward and backward. The lower portion of the shaft was split. A 
fragment 17 cm. long, composing nearly the entire thickness of the shaft, has united in a bad position. 
It points downward and outward and presents an anterior prominence. In its union with the con- 
dyles the latter has rotated outward 30 degrees. (Mutter Museum, No. 1397.069.) 

the soft parts and produce an open fracture. The lower fragments are 
displaced posteriorly and latterly. 

Symptoms. — The symptoms of intercondylar fractures are loss of 
function, false motion, bony crepitus, widening of the condylar region, 
separate mobility of the two condyles, at times the sinking in of the 



FRACTURES OF THE FEMUR 



515 



patella between the two condyles, shortening of the extremity, and 
prominence of the lower end of the upper fragment anteriorly. Some- 
times fixation in, and at times puncture of, the soft parts by a sharp 
upper fragment occurs. In addition there are great swelling, ecchy- 
mosis, joint effusion or hemorrhage, and local evidences of direct 
injury to the soft parts. 

Complications. — The complications of intercondylar fracture are 
injury to the popliteal artery and vein, the internal and external pop- 





Figs. 670 and 67 



rnal condyle of femur. Anteroposterior and lateral views. 



liteal nerves (Figs. 670 and 671), and perforation of the soft parts 
by sharp fragments of bone. 

Prognosis. — The prognosis in these cases is serious as regards life 
and function. Hennequin, according to Stimson, collected 26 cases 
of this variety, of which 16 recovered, 7 died, and 3 required ampu- 
tation. The degree of functional restoration will depend upon the 
perfection of reduction of fragments, the character of fragmenta- 
tion, and the subsequent amounts of callus formed. Cases in which 
good apposition of fragments is secured without widening of frag- 
ments and little joint callus, should be followed by fair functional 
result. 

Treatment. — Intercondylar lesions call for thorough reduction of 
fragments. General anaesthesia should be used, and reduction accom- 



516 



TREATISE ON FRACTURES 



plished by steady traction combined with manipulation and lateral 



paction of the condylar fragments with mallet and sand-bags is in- 
dicated after the best practical reduction has been obtained, may be 
of some use in lessening the subsequent production of intra-articular 
callus. A bone peg or a metal nail might be subcutaneously driven 
through the condyles to hold them together. Retention of fragments 
in their normal position may best be accomplished by the Buck traction 
apparatus, combined with posterior internal and external lateral 




Fig. 672. — Separation of the lower femoral epiphysis. Lateral and anteroposterior views. 
Characteristic deformity with the lower end of the diaphysis displaced posteriorly. Before reduction. 
(See Fig. 673). 

splints, and from ten to twenty pounds of weight. The suggestion of 
Robert Jones that the Thomas knee splint be used is worthy of 
thoughtful consideration. Immobilization should continue for six to 
eight weeks, followed by the use of a suitable leg brace or gypsum- 
gauze encasement. Y\ 'hen there is marked tendency toward dis- 
placement, traction should be made with the hip- and knee-joints 
flexed. 

Fractures of Either Internal or External Condyles (Figs. 670 
and 671). — Fracture of a single condyle is a very rare injury. Very 
few cases have been reported. 



FRACTURES OF THE FEMUR 



517 



Etiology. — These fractures may be the result of direct violence, 
and usually are due to forced abduction or adduction of the knee, to a 
twisting of the leg, or to direct force transmitted through the head of 
the tibia toward the involved condyle. The line of fracture is usually 
oblique, running upward from the intercondylar notch for a consider- 
able distance, producing a sharp spear-pointed fragment ; the line may 
be very short and end just above the condyle, or at the edge of the 
articular cartilage. 

Symptoms. — The symptoms consist in localized pain, tenderness, 
swelling, ecchymosis, effusion into the knee-joint, a valgus or varus 




Frag- 



position of the leg at the knee-joint, crepitus, and at times a moderate 
degree of displacement posteriorly and upward of the detached frag- 
ment. 

Prognosis. — The degree of function will depend upon the ac- 
curacy of reduction and the amount of intra-articular callus. Function 
may be expected to be somewhat impaired. 

Treatment. — Reduction may generally be accomplished by restor- 
ing the leg to its normal axis with the thigh, thereby controlling the 
position of the detached fragment by the action of the lateral liga- 
ments. Immobilization should be obtained by a posterior splint with a 



518 



TREATISE ON FRACTURES 



pad placed above the fractured condyle and pressure by adhesive 
plaster. If there is little displacement of the fragment the extremity 
may be immobilized in a plaster dressing. At the end of three to six 
weeks passive motion may be begun, and at the end of twelve to sixteen 
weight-bearing may be carefully attempted. 

Separation of the Lower Femoral Epiphysis. — The lower epiphy- 
sis of the femur includes the entire articular surface of the lower 
end of the bone. It is the largest epiphysis of the body, and unites 
with the diaphysis from the twentieth to the twenty-first year. Trau- 
matic separation of the epiphysis is most 
frequently observed about the tenth to 
twelfth year of life. 

Etiology. — Separation of the lower 
femoral epiphysis results from great vio- 
lence (Figs. 672-674), and as a result of 
abduction or hyperextension of the knee. 
The most frequent cause is the catching 
of the leg in the spokes of a rapidly 
revolving wheel. 

The line of separation definitely fol- 
lows the epiphyseal cartilage, to which is 
at times attached small fragments of the 
diaphysis. At times considerable strip- 
ping of the periosteum of the diaphysis 
occurs. The lesion, by reason of the vio- 
lence required to produce it, may be com- 
plicated with an open wound. The usual 
deformity is an anterior and lateral dis- 
placement of the epiphysis with, at 
times, rotation of the epiphysis upon a 
bilateral axis. This is considered by 
some authorities to be due to the pull of 
the gastrocnemius muscle inserted on the 
diaphysis, but in all probability it is due 
to the primary violence plus the pull of 
the extensor thigh muscles. 
Symptoms. — The symptoms of separation of the lower femoral 
epiphysis are the history of injury, great swelling, tenderness, and 
signs of severe local injury about the knee-joint, abnormal mobility at 
the knee-joint, soft cartilaginous crepitus when it is possible to bring 
the fragments into contact, marked deformity, and loss of function. 

The condition should be distinguished from supracondylar fracture 
and dislocation of the knee-joint. In supracondylar fracture crepitus 
is bony in character, the line of fracture is above the adductor tubercle, 




Fig. 674-— Femur; separation of lower 
epiphysis. Sh< >\vs normal epiphyseal lines 
of tibia and fibula. Case of Dr. R. H. 
Harte. (Mutter Museum. 



FRACTURES OF THE FEMUR 



519 



while in dislocation the disturbed relation of the tibia with the femur 
will generally be evident. In no other fracture is a radiogram of more 
importance for the determination of the exact lesion present. Exam- 
ination and reduction should be made under general anaesthesia. 

Complications. — The complications of 
epiphyseal separation are rupture or com- 
pression of the popliteal artery or vein, in- 
jury to nerves, and external wound causing 
an open fracture. Rupture of vessels may 
be incomplete, with resulting aneurism, 
while complete laceration of the vessels 
may give rise to severe hemorrhage and 
pressure gangrene. Contusion or pressure 
of the vessels may result in gangrene, and 
less frequently in thrombosis. Especial at- 
tention should be given to the color of the 
limb below the seat of fracture, and the 
presence or absence of pulsation below the 
seat of injury in the popliteal and tibial 
arteries should be carefully noted. 

Prognosis.— If reduction of the dis- 
placed epiphysis is readily accomplished, 
apposition of fragments maintained, and 
no vessel injury be present, union should 
be prompt and functional recovery perfect. 
From the lack of reported cases it is evident 
that separation of the epiphysis is not often 
followed by failure of subsequent develop- 
ment and shortening of the limb. When 
the epiphyseal separation is accompanied by 
laceration of large vessels, amputation is 
often a necessary result. 

Treatment. — In anterior displacement 
of the epiphysis, reduction may usually be 
accomplished under anaesthesia, by flexion 
of the thigh and leg. An assistant should 
make steady traction on the flexed leg in 
a line downward and at right angle to the 
long axis of the femur. The surgeon 
then grasps the lower portion of the thigh with the fingers of both 
hands in the popliteal space, and with the thumbs presses down- 
ward and backward on the epiphysis. This manipulation should be 
done at once, if there is evidence of pressure on the popliteal vessels ; 
when reduction is accomplished, the leg may be brought into position 




Fig. 675. — Separation of the lower 
femoral epiphysis. Drawing made after 
rontgenogram. (Figs. 672 and 673). 
Note the pull exerted by the gastroc- 
nemius muscle, A, in producing pos- 
terior displacement of the lower end of 
the diaphysis. 



.520 



TREATISE ON FRACTURES 



of partial extension and immobilized on a posterior splint, gypsum, 
gauze, wood or metal, or in a gypsum moulded encasement (Figs. 675 
and 676). Usually there is no tendency toward displacement after 
reduction is accomplished, as the rough surfaces of the broadened end 
of the diaphysis and the epiphysis tend to remain engaged. If reduc- 
tion tends to recur, the leg should be held flexed on the thigh at right 
angles and immobilized in a plaster dressing. When reduction cannot 
be accomplished by conservative measures, an incision should be made 
on the external surface and reduction accomplished by leverage com- 
bined with manipulation. 

In lateral and posterior displacements, reduction can usually be 
accomplished by flexion, manipulation, and traction. Reduction is evi- 
dent by the assumption of normal contour, soft crepitus at the time of 
reduction, and loss of tendencv to recurrence. Union occurs in from 




FlG. 676.— Method of red 



of separation of the lower epiphysis of the femur. 



four to six weeks. After this time a knee splint may be used, passive 
motion adopted, and weight-bearing allowed at the end of twelve to 
fourteen week-. 

If after open examination and reduction there is a tendency toward 
recurrence of the displacement, immobility should be obtained by 
direct fixation, preferably, perhaps, by a metal plate. As a rule, how- 
ever, it is not advisable to use an internal method of fixation unless 
absolutely necessary, owing to the possibility of inducing necrosis and 
interference with the subsequent development of the epiphysis. 

Sprain-Fractures of the Lower End of the Femur (Figs. 677 

-This rather infrequent form of fracture is a tearing off of 

a small part of the cortex of the bone in the region of the internal 

epicondyle. the adductor tubercle or the external epicondyle, or at the 

attachment of the tendon of the adductor magnus. the tendons of the 



522 



TREATISE ON FRACTURES 



gastrocnemius muscle, or at the point of attachment of the lateral 
ligaments. 

Etiology. — While direct violence may be the cause of a few of 
these fractures, the majority result from strain brought upon the 
attachment of tendons and ligaments, and result in a tearing off of 
irregular portions of bone of varying size. 

Symptoms. — The symptoms resemble those of a severe sprain of 
the knee-joint. There are severe pain, localized tenderness on pres- 





Fig. 681. — Method of determining abnormal mobility in fracture of the internal condyle of the femur 
by a forced valgus position. 

sure, ecchymosis, and an effusion of serum or blood within the knee- 
joint. The patient complains of a considerable loss of function due 
to pain and the effusion; strain brought upon the attachment of the 
involved tendons by a forced varus or valgus position increases this 
pain (Figs. 680 and 681) ; at times crepitus is detected and the pres- 
ence of a small movable fragment may become evident on painstaking 
examination. After union has taken place, there may develop, par- 
ticularly when the fragment has been detached by the pull of the 



FRACTURES OF THE FEMUR 



523 



adductor rnagnus tendon, an ossifying myositis of the involved tendon 
and muscle. 

Prognosis. — After adequate rest and subsequent careful massage, 
function should be fully restored. 

Treatment. — This consists almost entirely in immobilization in 
plaster or on a posterior splint 
for four to- five weeks until union 
is firm. This should be followed 
by massage, baking, and passive 
motion, and later the patient 
should be encouraged to use the 
parts. On account of the small- 
ness of the detached fragment 
open operation with direct fixa- 
tion is rarely demanded. 

Occasionally after a sprain- 
fracture occurring at the region 
of attachment of the adductor 
muscles, ossification in the sub- 
stance of the muscle (myositis 
ossificans traumatica) may occur. 
This is due to the deposit of bone 
cells from the detached perios- 
teum (Fig. 682). 

Summary of Non-operative 
Treatment 

Firm, level mattress without 
springs. 

Upper End of Femur. — In 
aged, handle with gentleness and 
care lest impaction be broken up. 
Do not attempt to obtain preter- 
natural mobility or crepitus. 
Treat as fracture of neck, until 
X-ray or result disproves diag- 
nosis, with Buck's longitudinal 
traction of about 6 to 10 lbs., and 
lateral support on both sides of 
injured limb. Some lateral traction below trochanter may be added. 

When diagnosis of fracture of neck is established, continue same 
method if patient bears confinement in bed well. If patient loses ground 
in general health, treat patient rather than fracture and let him care- 
fully assume sitting posture, even out of bed. 



. osites ossificans traumarica follow- 
ing strain of adductor muscles. Note ossification 
in substance of adduction muscles at its point of 
attachment to the femur. 



524 TREATISE ON FRACTURES 

In Young or Middle Aged. — May cautiously endeavor to obtain 
crepitus and abnormal mobility, using little force, but not suddenly. 

When X-ray confirms diagnosis and shows character of fracture 
lines, endeavor to reduce fragments and obtain proper coaptation by 
cautious flexion and full abduction, using general anaesthesia as an 
adjunct to the manoeuvres. 

Use Buck's longitudinal traction method horizontally or in abduc- 
tion with stable counter-traction : lateral traction outwards below tro- 
chanter in addition may be wise ; or Whitman's complete abduction 
method for both legs by means of a gypsum-gauze encasement, confin- 
ing both sides from nipple line to below knees. 

Shaft of Femur. — Subtrochanteric. — After reduction under ether 
and study of lines of break, put up fracture with hip partially flexed 
and the thigh somewhat everted and abducted to keep the upper and 
lower fragments coapted. Make traction in axis of thigh while in this 
posture by Buck's method with pulley placed high over lower part of 
bed, or with limb on an inclined plane, or with an anterior wire splint 
properly suspended to give traction in the needed direction. 

A gypsum-gauze encasement, including lower chest, abdomen, both 
hips and thighs, the opposite thigh lying horizontal, may be added to 
the traction appliance. 

Middle. — Reduction under ether, locking fragments if possible. 
Buck's longitudinal traction with sufficient weight — 15 to 40 pounds, 
not omitting stable countertraction. and lateral support. Traction may 
need to be a little above the horizontal axis of the normal limb. Re- 
member the anterior arching of the femur. Coaptation splints or 
encasing contour splint about the broken region of the shaft may be 
necessary, especially in comminuted or double breaks. 

Lower End of the Femur including supracondylar. Reduction. 
Buck's longitudinal traction and lateral support. Perhaps posterior 
popliteal support with splint needed. 

In all fractures of neck or shaft avoid weight bearing for several 
weeks after the union is believed to be solid. 



CHAPTER XXII 

FRACTURES OF THE PATELLA 

Anatomy. — The patella is a flat, somewhat triangular sesamoid 
bone in the tendon of the quadriceps extensor muscle of the leg. It 
has two surfaces, the anterior, which is convex, roughened, and sepa- 
rated from the cellulo-integument of the front of the knee by a bursa, 
and the posterior or articular surface, covered by articular cartilage. 
The upper end or base is broad and gives insertion to the tendon of the 
quadriceps extensor muscle. The lower end or apex gives attachment 
to the ligament of the patella. 

Surface Markings. — Relaxation of the extensor muscle allows 
palpation of the entire border of the patella, and furnishes a demonstra- 
tion of its mobility. In flexion of the leg the patella is carried down- 
ward over the condyles; in extension it is carried upward, so that in 
extreme extension only the lower half of the patella is in contact with 
the condyles of the femur. Laterally there are sulci ; and on flexion of 
the leg the articulating surfaces of the condyles may be palpated. 

Statistics. — Plagemann's statistics from the Rostock clinic, based 
upon the radiographic study of 1393 fractures, showed the patella to 
be fractured in 35 instances (2.51 per cent.). Of these 35 cases, the 
fracture involved the upper third 5 times, the middle third 22 times, 
and the lower third 8 times. In 17 instances the fracture line was 
transverse ; 2 times there was a superficial tearing out of the bone at 
the apex of the patella, and 4 times there was a fracture at the base of 
the patella with a separation of a three-cornered fragment at the attach- 
ment of the extensor tendon. In 9 cases the fracture line was trans- 
verse, with more or less penetrating longitudinal or oblique fissures, 
and in 2 instances there were typical stellate fractures. A clean longi- 
tudinal fracture was not observed during the preparation of this classi- 
fication, although later he observed two of this character and also saw 
two subperiosteal fractures. 

Etiology. — The etiology of the fractures in individual cases is often 
difficult to determine. Patients have difficulty in telling whether the 
fracture preceded the fall or was the result of it. Fractures of the 
patella are due to muscular action and to direct force. Fractures due 
to muscular action are occasioned by sudden and forcible contraction of 
the quadriceps extensor muscle, occurring during a mis-step in an 
effort to save oneself from falling, in the voluntary use of the leg, as 
in kicking or lifting a weight with the leg or back, or in resisting forced 

525 



526 



TREATISE ON FRACTURES 



flexion of the knee. The patient may attribute the fracture to a fall 
upon the knee when in fact the fracture preceded the fall and local 

Fig. 683. Fig. 684. 




FlG. 683. — Incomplete transverse fracture of the patella. 
Fig. 684. — Transverse fracture of the patella, lower third. 




FlO. 685. — Transverse fracture of the patella with marked rotation of the lower fragment. 
Fig. 680. — Transverse fracture of the patella, middle third, with separation of the fragments. 

evidences of contusion of the region of the knee are absent. The 
laceration of the fibrous covering of the patella and the tears in lateral 
expansions of the capsule of the joint, accompanying the break, are 



FRACTURES OF THE PATELLA 



527 



evidently produced by severe muscular pull and not by a local direct 
violence. Early and late refractures of a united patella may also be 
occasioned by muscular action. 




Pig. 687. — Incomplete transverse fracture of the patella, lower third; direct violence. 

FlG. 688. — Transverse fracture of the patella, middle third. Marked separation of fragments. 

Fig. 689. — Transverse fracture of the patella, with moderate bony union. 

Fig. 690. — Old transverse fracture of the patella, upper third, with extreme separation of the fragments. 

Fractures by direct violence are due to a direct fall upon the patella 
and to kicks and blows delivered directly over that bone. Patellar 



528 



TREATISE ON FRACTURES 



fractures are rarely seen before the twentieth year, and are most fre- 
quently met between the thirtieth and fiftieth years. They occur 
rarely in children, and more commonly among male adults than in 
women. 

Varieties and Mechanism. — Fractures of the patella (Figs. 683- 
690) may be transverse, oblique, comminuted, longitudinal, subperi- 
osteal, and closed or compound in 
character. Those caused by muscular 
action are usually transverse in direc- 
tion and closed ; occasionally they are 
merely a tearing off of the upper or 
lower cortical portion of bone. Frac- 
tures by direct violence are usually 
oblique, but are at times comminuted ; 
and occasionally they are accom- 
panied by a wound, causing them to 
be open fractures. 

In transverse fractures the line 
may occupy the upper, middle or lower 
third of the bone, but is usually in the 
middle third. Fractures by direct vio- 
lence may occupy any portion of the 
bone and be of any variety. 

Without entering into a discussion 
of the various theories of the mechan- 
ism of fractures of the patella, it may 
be stated that those produced by mus- 
cular action occur while the knee is 
partially flexed. The patella then is 
held firmly by the quadriceps muscle 
and the ligament of the patella against 
the condyles of the femur, a sudden 
contraction of the quadriceps muscle 
acts forcibly on the upper edge of the patella and the bone is broken 
transversely at its point of contact with the condyles. The resulting 
line of fracture depends upon the degree of flexion of the knee at the 
time of fracture (Fig. 691). When the patella breaks, the apo- 
neurosis and lateral expansion of the quadriceps tendon also may 
be torn by the muscular pull. The tear is of varying degree, from a 
slight tear in the aponeurosis over the patella to a complete rupture 
of l>oth lateral expansions of the joint capsule. In fractures by direct 
violence there are, as a rule, very little separation of fragments, very 
little tearing of the fibrous aponeurosis over the patella, or of the 
lateral expansion of the joint capsule. Tn transverse fractures in 




Fig. 691. — Drawing to show the mechan- 
ism of fracture of the patella by muscular 
action. 



FRACTURES OF THE PATELLA 529 

which the lateral expansion of the aponeurosis and joint capsule are 
torn, there is marked separation of the fragments. The lower frag- 
ment remains stationary, due to its ligamentous connection with the 
tibia, but the upper fragment is displaced upward; there may be 
separation amounting to from half an inch to an inch. This later 
may be increased greatly by rapidly occurring joint effusion and intra- 
articular hemorrhage, and the muscular contraction. Tilting of the 
fragments forward at the fracture is quite usual. 

Symptoms. — The types to be described are those due to muscular 
action, which usually show more or less separation of fragments, and 
those caused by direct violence, which generally have irregular lines 
of break with little if any separation of the pieces. In the two classes 
the symptoms, the prognosis, the form of treatment and the end results 
are different. 

The symptoms of fracture by muscular action, in which there are 
present separation of fragments and a transverse line of fracture in 
about 80 per cent, of cases, are sudden loss of power of extension at 
the knee, so that the patient cannot voluntarily straighten the flexed 
knee. Although at times he is able to extend the knee by the swinging 
leg with the thigh, he is unable to raise the foot from the bed when 
supine. Disability varies, however, with the amount of laceration of 
the tendinous aponeurosis surrounding the patella. The tendinous 
fibres of the vastus internus on the inner side and the prolongation of 
the fascia lata on the outer side are not always completely torn ; as a 
result limited extension of the knee may be possible. Pain not intense, 
tenderness on pressure, and marked swelling of the entire knee region 
anteriorly and laterally are found upon examination. This swelling 
is due to joint effusion and hemorrhage. It extends outside the joint 
into the soft parts, and can be felt directly beneath the skin in the area 
between the fragments. Ecchymosis may extend beneath the quadri- 
ceps femoris and under the skin of the thigh. The separated fragments 
may be felt distinctly ; and as a rule there is a marked interval between 
them, forming a transverse cutaneous groove into which one or two 
fingers may be laid. Crepitus may be obtained, if the effusion is small 
and muscular pull has not separated the fragments widely. This is 
readily developed by slowly pressing the fragments together and moving 
them laterally upon each other. This procedure is somewhat painful, 
but establishes the diagnosis. Under ether the muscular contraction 
which causes the separation is easily overcome and crepitus is found 
without causing pain. 

In fractures by muscular action there are no local signs of con- 
tusion or abrasion of the soft parts, unless the patient falls directly on 
the knee after sustaining the fracture. 

The symptoms of fracture by direct violence are localized pain, 



530 TREATISE ON FRACTURES 

tenderness on pressure, the presence of a contused, abraded, or lace- 
rated wound over the patella, effusion not only in the knee-joint but also 
in the prepatellar bursa. The muscular attachments are not torn 
away and the sesamoid patella is shortened rather than divided trans- 
versely. The loss of function is not due to marked inability to extend 
the leg. as in fracture by muscular action, but is due to pain. Patients 
are able to bear weight on the leg, and in many cases may walk. As 
there is little separation of fragments, crepitus and mobility of frag- 
ments may be readily determined. There is effusion of synovial fluid 
and at times blood into the knee-joint. The character of the swelling 
is, however, different from that seen in fractures by muscular action, 
in that it is similar to that seen in acute synovitis and rarely extends 
into the surrounding soft parts. 

In vertical, subperiosteal, and cortical fractures, the symptoms 
present may be only those of an associated traumatic synovitis and the 
true lesion only recognized by radiogram. Sometimes late ecchymosis 
over the bone and the development of a local swelling from callus may 
reveal the true character of the lesion. 

Differential Diagnosis. — Fracture of the patella should not be 
confused with rupture of the quadriceps tendon, rupture of the liga- 
ment of the patella, prepatellar bursitis, or traumatic synovitis of the 
knee-joint. A fracture of the bone is differentiated from rupture of 
the quadriceps tendon, which occasionally is torn from its attachment 
to the patella, by the absence of a sulcus above the bone and the pres- 
ence of downward mobility of the patella; from rupture of the liga- 
ment of the patella by the absence of a sulcus below the patella and 
possibility of upward mobility of the patella. Radiographic examina- 
tion will clear up the diagnosis. 

In prepatellar bursitis there may at times be felt a decided crepitus 
within the bursa, but it is soft in character, and there is no swelling at 
the sides of the knee-joint ; while traumatic synovitis may be differen- 
tiated by failure to discover two fragments of bone with a furrow 
between them, by the evident floating of an unbroken patella or an 
intra-articular effusion and the shape of the fluctuating fluid collection. 
Radiography will aid greatly in establishing a diagnosis. 

Prognosis. — The prognosis of fracture of the patella depends upon 
the character of the fracture, the degree of separation of fragment.-. 
the extent of the tear of the lateral expansion of the aponeurosis, and 
the form of treatment adopted. Bony union results only when ana- 
tomical apposition of fragments is obtained. Tn transverse fractures 
with separation of fragments, bony union is defeated by the want of 
coaptation, the interposition of torn edges of the aponeurosis, dropping 
inward between the fragments, and by the action of synovial fluid, 
which limits to a great extent the formation of callus. Union in cases 



FRACTURES OF THE PATELLA 531 

in which there is uncorrected separation of fragments is never bony 
but fibrous in character. While fairly useful function may be obtained 
thus, it requires several months or a year for its establishment, and is 
not of a character to stand much strain. Resulting stretching of the 
fibrous union often takes place ; and approximation, which at first was 
fairly close, ends in a considerable separation of fragments, so that 
eventually they may be separated for a distance of from three to four 
inches. In transverse fracture it is only in those cases, in which there 
is little or no tearing of the lateral expansion of the aponeurosis, that 
a completely useful joint is obtained. In fractures by direct violence 
in which there is an oblique, comminuted line of fracture and no tear- 
ing of the aponeurosis and therefore no appreciable separation of 
fragments, bony union as a rule results and operative treatment is not 
indicated. In transverse fractures with separation of fragments, 
operation and direct approximation of fragments with repair of 
aponeurotic tears should give firm bony union and good functional 
results. Before selecting the operative method of treatment the pos- 
sibility of sepsis should be made known to the patient ; but he should 
be informed that by operation firm bony union will be obtained in the 
majority of cases with consequent shortening of the time of conva- 
lescence. The possibility of infection occurring in open treatment on 
the one hand and the probability of fibrous union with resulting func- 
tional impairment and prolonged convalescence by non-operative 
means on the other hand should be made clear to him. He should 
realize that the open treatment, which means suture of the fascia and 
aponeurosis and perhaps of the bone, is dangerous in the hands of the 
occasional surgeon, but practically free from danger when performed 
under a skilled modern technic. 

Treatment. — To obtain good functional results in fractures of the 
patella there must be almost anatomical apposition of fragments, 
which will give bony or a short fibrous union. This is less likely 
to occur under non-operative treatment, though it is practically pos- 
sible in fractures with moderate laceration of the tendinous surround- 
ings of the patella. A satisfactory approximation of fragments is 
liable to be prevented by intra-articular hemorrhage, contraction of 
the quadriceps extensor muscle, and interposition of torn edges of 
aponeurosis and periosteum. In fractures by direct violence, in which 
as a rule there is little or no separation of fragments and no inter- 
position of aponeurosis, and in fractures by muscular action in which 
the fragments are little separated, the non-operative treatment is satis- 
fying. The non-operative treatment consists in putting the entire 
extremity at rest on a posterior padded splint, with the knee in full 
extension, the leg elevated, and the thigh muscles relaxed by flexion at 
the hip-joint. This form of treatment, combined with local cold inter- 



532 TREATISE OX FRACTURES 

mittently applied, and after the first week moderate compression by 
bandages, will give firm union, fibrous or osseofibrous, as a rule at the 
end of about six weeks. At the end of this time the splint may be 
removed, judicious passive motion and massage instituted, and at the 
end of three months active use of the leg allowed. This form of 
treatment has. however, a rather limited degree of usefulness, and 
should be used only when there is no marked separation of fragments 
and a competent operative technic is unobtainable. 

In transverse fracture of the patella with separation of fragments, 
two forms of treatment may be adopted — non-operative and operative. 
Successful non-operative treatment in the average case, as a rule, will 
give moderately close fibrous union and fair functional results after 
a prolonged convalescence; it should be adopted only when there is 
some direct contraindication to operation or after the possibilities of 
the two forms of treatment have been thoroughly understood by the 
patient. Operative treatment, on the other hand, should give bony 
union, good functional result, and a much shorter convalescence. It 
is advisable when the operator is a surgeon accustomed to carrying 
out an aseptic technic and can assume with safety the treatment of 
possible septic complications. 

Non-operative Treatment ( Fig. 692. ) — Place the foot, leg and 
thigh upon a well-padded posterior wood or wire splint with foot- 
piece. Bandage the leg and thigh to the same ; or use four straps of 
adhesive plaster two inches in width for that purpose applied as shown 
in the illustration. Steady the lower fragment by a strap of adhesive 
plaster passed obliquely around the leg immediately beneath the lower 
fragment, elevate the splinted limb to flex the hip and relax the thigh 
muscles, place a second strip of adhesive plaster obliquely around the 
of apparatus for a period of from four to seven weeks, changing it 
occasionally and giving light massage to the muscles. From time to 
time it will be necessary, especially during the first two week>. to 
tighten the adhesive stripping above and below the patelia so as to 
maintain approximation of fragments. Do not flex the knee during 
the treatment. At the end of eight weeks the elevation may be dis- 
continued and the limb brought to the extended position, and at the 
end of a few days replaced by a light split plaster dressing or posterior 
ham splint 1 Fig. 093 >. Weight-bearing may be begun at about eight 
weeks while the ham splint is continued. Passive flexion of the knee 
may be started carefully at about ten weeks. Active motion should not 
be allowed until about the end of the third to the sixth month. 

Operative Treatment. — Strict asepsis is absolutely necessary in 
operations upon the patella. Unless one is prepared to be most exact- 
ing in technic. non-operative methods are advisable. Operation- for 
repair of a broken patella should be done only in well-appointed hos- 



FRACTURES OF THE PATELLA 



533 



pitals and by those who are daily engaged in major operative work. 
There is no joint which is more prone to infection and in which more 
disastrous consequences follow it than the knee-joint. Infection 
means prolonged convalescence at best, and gives rise to suppurative 

Fig. 692. 




Fig. 692. — Method of non-operative treatment of fracture of the patella on inclined plane. The 
leg is fixed securely by straps of adhesive plaster to the splint, and the fragments of the patella are 
approximated by two strips of adhesive plaster shown. Elevation of the leg is then made to relax the 
quadriceps extensor muscle. 




arthritis, subsequent ankylosis, suppurative myositis, failure of union, 
and even death. The end-result of suppurative knee-joints, following 
operation for fracture, is therefore deplorable. 

An .operation for patellar fracture is best performed at the end of 



534 



TREATISE ON FRACTURES 



from three to five days after injury, though there is no great objection 
to earlier intervention. A transverse semicircular incision with con- 
vexity upward, to keep the scar from the kneeling surface, raises a 




Fig. 694. — Fracture of the patella. Middle dressing shows crescentic incision with edges retracted, 
transverse fracture of patella with tear of aponeurosis, and lateral expansion of the capsule. Lateral 
figures show method repair with interrupted kangaroo tendon and chromic catgut sutures approxi- 
mating fragments and torn capsule, interrupted linear sutures in skin and rubber tissue drains in both 
angles of the wound. 

flap over the broken bone and uncovers the seat of fracture. The 
synovial fluid escapes and the blood-clots should he picked out with 
forceps. Irrigation of the joint is not advised. The torn edges of the 
aponeurosis and the periosteum covering the patella arc lifted from 



FRACTURES OF THE PATELLA 535 

the fractured surfaces, which are lightly rubbed with dry gauze to 
remove adherent blood-clot and fibrin. The fragments of the patella 
are brought together and held in approximation by a circumferential 
suture of No. 2 chromic catgut, or by two interrupted sutures of 
No. 2 chromic catgut placed at the lateral edges of the patella. The 
lacerated aponeurosis and periosteum covering the patella and the 
torn margins of the lateral expansions of the joint capsule are sutured 
with interrupted or mattress sutures of No. 1 chromic catgut, and the 
skin edges with interrupted sutures of fine silk. The wound is closed 
with drainage at each angle of the wound, a sterile dressing is ap- 
plied (Fig. 694) , and the leg and thigh, on a padded posterior splint of 
wood with the hip flexed moderately, are fixed on an inclined plane. 
Massage and passive motion should begin at the end of the third week 
and active motion and weight-bearing at the end of three months. 
The result looked for is bony union, which generally occurs if ana- 
tomical approximation is maintained. With proper technic infection 
is extremely rare. 

In transverse fractures Wyeth passes by means of a needle a deep 
transverse cord through the ligament of the patella and the overlying 
skin close to the bone. Just above the patella he carries another liga- 
ture deeply through skin and muscle across the thigh. These have their 
ends sticking out of the skin at four points, two above and two below 
the broken sesamoid bone. Placing a pad of gauze over the seat of the 
fracture, he ties the respective upper and lower ends of the threads 
together so as to displace any periosteal fringe lying between them. 

Results. — W. C. Quinby reports the results of 30 cases out of 75 
treated at the Massachusetts General Hospital, from 1898 to 1904. 
Six of the cases were treated without suture and 24 with suture, 2 of 
the latter having a double fracture. Of the 24 cases, 7 were reoperated 
upon for refracture and two for removal of the suturing wire. The 
results obtained were as follows : 



Unsutured, 6 Cases 

E.esult Per cent. 

Perfect 3 50.0 

Fair I 16.5 

Poor 2 33.5 

Serviceable knees 66.5 



Sutured, 24 Cases, 26 Operations 

Result Per cent. 

Perfect 17 65.5 

Fair 5 19.0 

Poor 4 15.5 

Serviceable knees ' 84.S 



536 TREATISE OX FRACTURES 

Perfect results included cases having normal voluntary extension 
and flexion, 8, 18 degrees and 34 degrees, respectively, with perfect 
function. In fair results were included those having voluntary flexion 
to a right angle or a little less, with no limp or trouble in walking on 
the level : and in poor results were those in whom flexion to a right 
angle was impossible, who limped or became easily tired on the level. 
or who required a cane or had to go upstairs one step at a time. While 
this group is rather small, it gives a fair idea of the two classes of 
treatment, but it should likewise be remembered in a study of these 
statistics that those cases selected for operation probably had wide 
separation of fragments and that the non-operated group had little 
separation of fragments. 

End-results. — Delatour reports the following statistics : 87 patients 
with 103 fractures; 3 cases not operated upon. Two deaths occurred 
but neither was directly due to operation. In 99 instances the frac- 
ture was exposed and sutured. Six had useful joints, but with limited 
motion ; 40 had flexion to, at least, a right angle, with perfectly useful 
joints. The remainder he was unable to trace. All had motion to at 
least 45 degrees at the time of leaving the hospital. 

Refracture of Patella. — Ref racture of a previously fractured patella 
is sometimes observed and is due to muscular pull from mis-steps or 
stumbles, or it may be occasioned by a recurrence of the original form 
of injury. It is seen most frequently in recent cases of fracture, in 
which the bond of union is not strong or in which the joint structures 
have not regained their normal pliability and the muscular structures 
their normal tone. The line of refracture is, as a rule, at the original 
break. The upper fragment is torn away from the lower fragment, 
and on flexion of the knee-joint this separation is increased, while hyper- 
extension gives good approximation. 

The treatment consists in immobilization of the part on a posterior 
splint, with approximation of the fragments by the adhesive plaster 
dressing and an increased convalescence with careful massage and 
passive motion. Rarely open operation and direct fixation of the frag- 
ments by suture of the periosteum or bone or by a circumferential 
suture of chromic catgut or kangaroo tendon may be required. 

Old Fractures of the Patella.— Old fractures of the patella with 
fibrous union may be characterized by marked separation of the frag- 
ments and impaired function. In such cases operation should be per- 
formed when the disability is great and the probability of improvement 
in function evident. Separation of fragments alone in the presence 
of a fairly useful limb is not an indication for operation. By operating 
on these patients, it may l>e possible to obtain union after freshening 
the fragments and approximating fragments by traction and suture. 
In this class alone is direct drilling of the fragments and the us 



FRACTURES OF THE PATELLA 537 

some form of non-absorbable suture, such as silver or iron wire, ad- 
visable (Figs. 695 and 696). When approximation of fragments 
cannot be obtained by traction, the fragments may at times be brought 
together by lengthening of the quadriceps extensor tendon. This may 
be accomplished by several lateral transverse incisions in the tendon, 
by transverse incision of the fascia over the rectus, or by the reflection 
of a part of the quadriceps tendon downward, placing it over the two 
portions of the patella and attaching it to the ligamentum patella. 
Scharrz reports the transplantation of the lower half of the sartorius 
muscle to a position in front of the patellar fragments and suture to 
the latter by wire sutures, with a good functional result. A fracture 

Fig. 695- Fig. 696. 




Fig. 695. — Fracture of patella, untreated for six months. (See Fig. bgO.) 

Fig. 696. — Fracture of the patella showing moderate approximation by silver wire suture. Good 

functional result obtained. (See Fig. 695.) 

had occurred five years previously with separation of the fragments at 
the time of operation of twelve centimetres (Figs. 697 to 700). 

Rupture of Quadriceps Extensor Tendon. — Rupture of the quad- 
riceps extensor tendon is always the result of sudden muscular action, 
usually in an effort to prevent oneself falling or making a mis-step. 
Cases have been reported in which pathologic conditions have pre- 
disposed to rupture. 

The rupture may take place at the junction of muscle and tendon, 
in the tendon itself, or at the point of insertion of the tendon with the 
upper edge of the patella. In the latter variety there is usually a small 
cortical fragment detached from the patella. The rupture may be 
complete or incomplete. 

Symptoms. — The symptoms of complete rupture are total inability 
to extend the leg, pain, localized tenderness, the presence of a sulcus 



538 



TREATISE ON FRACTURES 



above the patella, and evidences of joint effusion. When the lateral 
expansions of the aponeurosis are also torn, the disability is as com- 
plete as in similar fracture of the patella, and the other symptoms like 
those of patellar fracture without separation of fragments. 

Fig. 697. Fig. 69S. 




PlCS. -00. — Examples of suture of patellar fragments in which the silver wire 

used for suture was either extruded or broken. This form of operative treatment for recent fractures 
is not advised. These illustrations are only shown to demonstrate unwise methods of treatment. 

The symptoms of incomplete rupture are localized pain, swelling, 
joint effusion, pain on extension of the leg. no distinct failure to fully 
extend leg. but that movement is done with decreased force, and there 
is a slight gap. shallow and irregular in character, above the patella. 

Prognosis. — When there is complete rupture disability will be 



FRACTURES OF THE PATELLA 539 

prolonged and as a rule permanent, unless direct suture of the edges of 
the torn tendon is performed. This procedure should give a good 
functional result. In incomplete rupture, good functional results are 
obtained by immobilization for four to six weeks, and direct suture is 
not always demanded. 

Treatment. — In incomplete rupture the leg and thigh should be 
immobilized upon a splint and the foot elevated so that flexion at the 
hip-joint is maintained. This procedure relaxes the quadriceps ex- 
tensor muscle. Local compression should be applied to the knee-joint 
for one week and followed by massage of the thigh muscles. At end 
of fifth week splint may be removed and active motions encouraged. 

In complete rupture, incision with direct suture of the torn edges 
of the tendon is indicated. Chromic catgut or kangaroo tendon should 
be used to overlap the edges of the torn tendon with mattress stitches 
and post-operative treatment as recommended for incomplete rupture 
employed. 

Rupture of the Ligament of the Patella. — Rupture of the liga- 
ment of the patella is usually the result of muscular action, as in frac- 
ture of the patella and rupture of the quadriceps tendon, and rarely the 
result of direct violence. 

Rupture may occur in the body of the ligament or at either ex- 
tremity. When the proximal end is involved, small cortical fragments 
may be torn from the lower edge of the patella, and when the distal 
end is torn, small fragments of bone are usually separated from the 
tuberosity of the tibia. The rupture is usually complete. 

Symptoms. — The symptoms of complete rupture of this ligament 
are localized pain, tenderness on pressure, inability to' extend the leg, 
effusion into the knee-joint, the presence of a distinct sulcus below the 
patella, and upward displacement of the patella, which is increased by 
active contraction of the quadriceps extensor muscle. At times the dis- 
placement upward of the patella may be from one to two inches. 

Prognosis. — Fibrous union occurs with conservative measures, 
but there is apt to result permanent impairment of function, with 
atrophy of the extensor muscle, and the patient is obliged to use a cane 
permanently. Operation and direct suture give better functional results. 

Treatment. — Conservative measures are not recommended. Un- 
less there is some distinct contraindication to operation, it should be 
performed. Direct suture with chromic catgut or kangaroo tendon 
gives the best results. When the tendon is torn from the tuberosity of 
the tibia, direct nailing may be adopted. After operation the leg and 
thigh should be immobilized with the knee hyperextended and the hip- 
joint flexed. Massage and gentle passive motion may be started at the 
end of the fourth to fifth week or earlier, and active motion encouraged 
at the end of the eighth week. 



CHAPTER XXIII 

FRACTURES OF THE TIBIA AND FIBULA 

Anatomy. — The tibia I Fig. 701) is the larger and inner bone of 
the leg. and supports the weight of the body from the femur to the 
astragalus. It consists of the upper extremity, the shaft and the lower 
extremity. The upper extremity of the tibia is the largest and broadest 
part of the bone and consists of the internal and external tuberosities, 
which have upon the upper surface the internal and external articular 
surfaces for articulation with the condyles of the femur. Between the 
two articular surfaces is a prominence, the intercondylar eminence with 
two elevations, the internal and external. Anteriorly below the in- 
fraglenoid margin there is a large roughened projection, the tubercle. 

The shaft of the tibia is three-sided, is largest at its junction with 
the upper extremity and gradually tapers until near its lower end 
where it again becomes somewhat increased in diameter. It presents an 
internal and external surface, separated from each other by the crest, 
and a posterior surface separated from the inner surface by the rounded 
inner border, and from the external surface by the interosseous ridge. 

The lower extremity of the tibia while smaller than the upper ex- 
tremity is larger than the shaft. Its lower surface articulates with the 
astragalus; from its lower inner side there is a process, the internal 
malleolus, having an articular external surface for the joint with the 
astragalus. The outer surface of the lower end presents a fibular notch 
for articulation with the fibula. 

The fibula (Fig. 702) is the slender bone of the leg situated ex- 
ternal to the tibia. It is slightly shorter than the tibia and consists of 
the upper extremity, the shaft and the lower extremity. The upper 
extremity is formed by the head, the upper part forming the apex, and 
pre>enting a small articular facet for the tibia. The shaft has three 
surfaces — the internal, external and posterior, and three crests — the 
anterior, external and internal. The lower extremity presents an 
enlarged pyramidal process, the external malleolus, situated a little 
lower and posterior than the internal malleolus. It presents two facets. 
one for articulation with the tibia and the other for articulation with 
the astragalus. 

The tibia and fibula are connected in three ways : at the upper tibio- 
fibular articulation, by the anterior and posterior superior tibio-fibular 
ligaments; in the region of the shafts by the interosseous membrane, 
and at the lower tibio-fibular articulation by the inferior interosseous 
ligament and the anterior and posterior inferior tibio-fibular ligaments. 

MO 



FRACTURES OF THE TIBIA AND FIBULA 



541 



The ligaments of the articulation of the femur and tibia have been 
described above. 

The ligaments about the ankle-joint in addition to those of the 
tibio-fibular joint connect the two bones of the leg with the astragalus 
and os calcis of the tarsus. They are the deltoid or internal lateral 
ligament, which consists of f our separate ligaments, — the anterior talo- 
tibial, the posterior talo-tibial, the calcaneo-tibial and the tibio-navicu- 
lar ligaments; and the external lateral ligament, consisting of three 
parts — the anterior, the middle and the posterior fasciculus. 



Spine 
External condylar surface 




Internal condylar surface 



Bursal surface 



Anterior border of crest 



Interosseous border 



Internal surface 



For astragalus — — JJjp— Inter 

Pig. 701. — Right tibia, anterior view. 

Surface Markings.— Palpation of the region of the knee-joint and 
upper part of the leg discloses the ligament of the patella in the 
median line and in the line of the tubercle of the tibia to which it is 
attached. The external and internal tuberosities may be palpated, the 
external being the more prominent of the two. Between the tube- 
rosities of the tibia and the condycles of the femur are the two respective 
depressions. In either of these may be felt after certain traumatisms 
the dislocated semilunar cartilage of the injured side of the joint. On the 
external and posterior margin of the leg may be felt the head of 
the fibula at the level of the tubercle of the tibia. Posteriorly is seen 



542 



TREATISE ON FRACTURES 



the popliteal space in which may be felt the pulsation of the popliteal 
artery, which is of importance in supracondylar fractures of the femur. 
Anteriorly the prominent crest of the tibia, the shin, may be seen 
and palpated, as well as antero-internal surface of the shaft of the 
tibia. The shaft of the fibula can only be indefinitely palpated, except 
at its lower fourth, where it becomes subcutaneous. At the ankle the 
most prominent parts are the external and internal malleoli, the ex- 
ternal being a little lower and on a plane posterior to the internal. 
Normally the internal malleolus should be on a line drawn from the 

. Facet for tibia 
-Head 



Posterior-external border 



-external border - 



External surface ( 



Interosseous border 



Anterior surface 
Postero-interna 



For tibia 
External malleolus Hit J— Articular surface for astragalus 
Fig. 702.— Right fibula, anterior view. 

inner border of the patella to the inner side of the head of the first 
metatarsal bone. Posteriorly is seen the tendon of Achilles, which is 
narrowed at the level of the internal malleolus. At this point it is 
preferably cut in subcutaneous tenotomy, when this operation is re- 
quired to prevent displacement of the fragments in fractures of the 
tibial shaft caused by spasm of the gastrocnemius. 

Statistics. — Plagemann's statistics based on radiographic diagnosis 
of [393 fractures observed at the Rostock clinic shows that the tibia 
and fibula were involved in 286 cases (20.53 per cent.), classified as 
follows: 



FRACTURES OF THE TIBIA AND FIBULA 543 

Cases Per cent. 

Fractures of tibia and fibula 168 12.06 

(1) Fractures of the upper end of the tibia and fibula. ... 4 0.29 

(2) Fractures of the shaft of tibia and fibula 92 6.604 

(3) Supramalleolar fractures of tibia and fibula (Malgaigne) 22 1.57 

(4) Fractures of lower end of tibia and fibula 50 3.59 

Isolated fractures of tibia 61 4.38 

Fractures of upper end of tibia 19 1 -3^> 

Fractures of shaft of tibia 24 1.79 

Fractures of lower end of tibia 18 1.29 

Isolated fractures of fibula 57 4-79 

Fractures of head and neck of fibula 13 0.43 

Fractures of shaft of fibula 30 2.15 

Fractures of lower end of fibula 14 1.005 

Fractures of the Upper End of the Tibia and the Fibula. — Fracture 
of the upper end of the tibia may occur as an isolated injury or may 
have an associated fracture of the upper end of the fibula. In a ma- 
jority of instances fractures of this extremity of the tibia are not 
accompanied by fracture of the upper end of the fibula. 

Etiology. — These fractures are the result of direct or indirect 
force. Fractures by direct violence result from blows, falls, and 
crushing injuries applied to the upper part of the leg. Fractures by 
indirect violence result from lateral or anteroposterior flexion with 
either the thigh or the leg and foot fixed. These injuries are essen- 
tially bending fractures. Forced abduction usually produces a frac- 
ture of the internal tuberosity, forced adduction, a fracture of the 
external tuberosity, and hyperextension an oblique fracture with the 
line of fracture running downward and forward. A rare form of 
fracture is the " compression fracture " of "Wagner, due to a fall from 
a height, the patient landing on the foot and producing a fracture of 
one or both tuberosities with marked crushing of the tuberosities and 
lateral displacement of the same. Fracture by indirect violence as a 
rule involves only the tibia, although rarely there are exceptions to 
this rule. 

Varieties (Figs. 703—727). — From a collection of 29 radiographs 
of fracture of the upper end of the tibia and fibula the following 
varieties of fracture were found: of tibial tubercle, 2; comminuted 
of the tibia and fibula, 1 ; of external tuberosity and of fibula, 1 ; of 
fibula alone, 2 ; longitudinal T-fracture of tibia with separation of 
both tuberosities, 4; compression fractures of tibia, both tuberosities, 
4; lateral oblique fracture of tibia not entering joint with fracture of 
fibula, 3 ; lateral oblique of tibia not entering joint, 2 ; anteroposterior 
fracture of tibia not entering joint, 1 ; fracture of external tuberositv 
of tibia, 2 (large fragment) ; external tuberosity of tibia, 1 (small 
fragment) ; transverse of tibia, 1 ; transverse of tibia with fracture of 
fibula, 1 ; fracture of intercondylar eminence, 1 ; and in childhood 3 



544 



TREATISE ON FRACTURES 



Fk 




-tibia] tubercle 




• .blique fra but involving only the 

diaphv>i<. one of these being associated with fracture of neck of fibula. 
Symptom- — fracture of the upper end of the 



FRACTURES OF THE TIBIA AND FIBULA 545 

Fig. 707. Fig. 708. 





546 



TREATISE ON FRACTURES 




Figs. 711 



— Longitudinal T- or Y-fracture of the upper end of the tibia, with separation of 
both tuberosities. Anteroposterior and lateral views. 




FRACTURES OF THE TIBIA AND FIBULA 



547 




548 



TREATISE OX FRACTURES 

Frc. 718. Fig. 719- 




tibia vary with the variety of fracture and the size of the fragment. 
There is always localized pain, tenderness on pressure, localized swell- 
ing, and when the fracture line involves the knee-ioint effusion of 



FRACTURES OF THE TIBIA AND FIBULA 549 

Fig. 722. Fig. 723. 





Fig. 725. 





550 



TREATISE ON FRACTURES 



synovial fluid and blood into the knee-joint. In fractures of either 
tuberosity there is always abnormal mobility, positive passive abduc- 
tion or adduction of the leg, and widening of the external measure- 
ments of the head; when there is absence of impaction of fragments, 
which is the rule, crepitus is present on motion. In T-fractures there 
may be marked widening between the tuberosities, mobility of frag- 
ments on each other, and the mobility of the leg in all directions from 
the seat of fracture. Voluntary motions of the leg are greatly re- 
stricted on account of pain and the lack of support. In compression 
fractures, widening of the tuberosities is more marked than in any of 
the foregoing varieties, and in addition there is shortening of the entire 




Fig. 726.— Anteroposterior oblique fracture of the upper end of the diaphysis of the tibia. Fracture 

does not involve the epiphyseal line. 

Fig. 727.— Incomplete transverse fracture of the upper ends of the tibia and nbula. 

leg. Displacement of fragments is due to gravity and the fracturing 
force. Palpation shows irregularity of outline, mobility, and displace- 
ment. Positive diagnosis as to the variety of fracture and displace- 
ment of fragments should be made by the radiogram. 

Fractures occurring in childhood may be incomplete and at times 
impacted In the " green-stick " fracture, which is usually oblique and 
does not involve the joint, the most notable symptoms are localized 
pain, swelling, tenderness on pressure, angulation at the seat of frac- 
ture,' absence of widening between the margins of the tuberosities, and 
absence of crepitus and abnormal mobility. 

Prognosis.— When good apposition of fragments is obtained, 



FRACTURES OF THE TIBIA AND FIBULA 551 

union is usually prompt. There is, however, a tendency toward the 
production of considerable callus, and as reduction of fragments is 
rarely complete, the normal joint surfaces are at times interfered with. 
There may be considerable diminution of function for a long time, if 
the line of fracture involves the joint, even when the reduction has 
been satisfactory. 

Complications. — In comminuted fractures or in fractures at- 
tended by marked displacement of fragments, there is the possibility 
of injury to the tibial arteries or popliteal vein, which may subsequently 
lead by gangrene to amputation. The external popliteal nerve may 
be injured in fractures involving the external tuberosity of the tibia or 
the head and neck of the fibula, and the subsequent development of 
callus may involve the nerve. This nerve lesion causes ankle-drop 
from motor palsy, if the injury to the nerve be severe. 

Treatment. — Treatment consists in reduction of fragments, which 
may be accomplished by traction, manipulation, and lateral jam- 
ming, particularly in longitudinal, T-fractures, and compression frac- 
tures. In fractures of either tuberosity involving the joint cavity, re- 
duction may be accomplished by forced abduction or adduction as the 
case requires. Retention of fragments may best be accomplished by 
the use of a gypsum dressing extending from the toes to the upper 
thigh. Correction of backward or lateral displacement of fragments is 
important. Permanent traction is not indicated, except in the com- 
pression form of fracture ; then it may best be obtained by using a 
Thomas knee splint. Union occurs in from six to eight weeks, but 
weight-bearing should not be allowed for three months, although pas- 
sive motion and massage may be given at the end of the third to the 
fourth week. Light massage and very careful passive motion may 
begin in experienced surgical hands a few days after reduction of the 
fragments. 

Isolated fractures of the upper end of the tibia will not be con- 
sidered separately, because the symptoms, diagnosis, and treatment are 
identical, whether the fracture is isolated or combined with a fracture 
of the upper end of the fibula. The only noteworthy fact in this con- 
nection is the relative frequency of their occurrence. In 29 fractures 
of the upper end of these bones fracture of both bones was found 8 
times, isolated fracture of tibia 15 times, and isolated fracture of the 
fibula 3 times. 

Isolated Fractures of the Upper End of the Fibula. — Isolated frac- 
ture of the upper end of the fibula is extremely rare (Figs. 728—730). 
In three cases observed the line of fracture involved the neck in two 
instances, and in the third case the line of fracture involved the upper 
end of the shaft near the neck. In all, the line of fracture was oblique 



552 



TREATISE ON FRACTURES 






FRACTURES OF THE TIBIA AND FIBULA 



553 



;# 



in direction and was caused by direct violence in the form of a kick. 
Muscular action due to pull of the biceps muscle may occasionally 
produce a fracture. 

Symptoms. — The symptoms are localized pain, tenderness, and 
possibly at times crepitus. Pain is often referred in the course of the 
external peroneal nerve ( Fig. 731). 

Treatment. — There is, as a rule, little if any displacement. The 
fragments are held together by the attachment of the muscles arising 
from this region. Immobilization on a posterior padded wood splint 
or in gypsum dressing for four - 
to six weeks should give good 
results. The development of 
considerable callus may produce 
pressure upon the external pop- 
liteal nerve, and later require 
excision of the callus. Weight- 
bearing may be begun early, 
because the upper end of the 
fibula has no part in the forma- 
tion of the knee-joint. 

Avulsion of the Tubercle of 
the Tibia (Figs. 774-776). — 
The tubercle and upper epiphysis 
of the tibia ossifies from a single 
centre, and unites with the dia- 
physis from the twenty-first to 
the twenty-second year. The 
tubercle at first is cartilaginous, 
and ossification extends down- 
ward from the epiphysis as a 
long tongue-shaped projection. 

Etiology. — The ligament of 
the patella extends from the tip 

Of the patella tO the tubercle Of Fig. 731.— Drawing to show the relation of the 

. ., . /-\ 1 j.- r ,1 external peroneal nerve with the head and neck of the 

tile tlDia. UnlV a portion Ot the fibula. Fractures in these regions are often associated 

t- ,.- , 1 |- .1 . . with severe pain due to nerve injury or pressure. 

ligament is inserted directly into 

the tubercle. Avulsion of this tubercle is the result of sudden contrac- 
tion of the quadriceps extensor muscle, the pull of which is transmitted 
through the patellar ligament to its point of insertion on the tubercle. 
In very rare instances it is the result of direct violence, as is undoubtedly 
seen in cases showing distinct fragmentation of the tubercle. It is 
essentially an injury of childhood and early adult life. 

Symptoms. — There is usually a history of strain, followed by pain 
and localized tenderness in the region of the tubercle. In addition 




.554 



TREATISE ON FRACTURES 



there is lameness and inability to fully extend the leg on account of 
pain ; on palpation there may be felt thickening of the region of the 
tubercle or a movable fragment, with perhaps crepitus, which is car- 
tilaginous in character. Radiographic diagnosis is possible only when 
there is marked separation of the ossified portion of the tubercle in 
comparison with the normal side. It is not improbable that errors 
have been made in the correct interpretation of radiographic plates of 
this region. 

Treatment. — When there is marked separation or humping of the 
tubercle, immobilization with localized pressure should be used for 
a period of five to six weeks. The ultimate re- 
sult of this lesion is good. The feasibility of 
operation and direct nailing of the displaced 
fragment is scarcely ever warranted, as the dis- 
placement has no effect upon the function of the 
patellar ligament, which is not entirely inserted 
into the tubercle of the tibia. 

Separation of the Upper Epiphysis of the 
Tibia and Fibula (Fig. 732). — This is a very 
unusual lesion. There have been found re- 
ported only 26 cases. The rarity of the injury 
is due to the comparative smallness of the epi- 
physis and the relation of the ligaments to the 
direct force, usually hyperextension or violent 
abduction or adduction of the leg. The tongue 
of cartilage forming the tubercle of the tibia is 
generally displaced with the epiphyses. The sepa- 
ration occurs in patients from three to twenty 
years of age. The usual lesion produced by 
fig. 732.— Tibia, fracture of the kind of violence which occasionally produces 

the head of; epiphyseal. The . . . , , . ,. • . 

specimen consists of the adja- this epiphyseal separation is a diastasis of the 

cent extremities of the femur .,.,,. ... , 

and tibia of the left ?ide and lower epiphysis of the femur or an oblique trac- 

removed from a child about ten « • • -1 • 

years old. The separation is ture through the tuberosities of the tibia. 

complete; the epiphysis is held ° 

lnents iti (Matter e M C useum li No" Symptoms. — The symptoms of separation of 
I442 - o6 - ) the upper epiphysis of the tibia are displacement 

of the upper fragment either laterally or anteroposteriorly forward, 
causing deformity, mobility of the fragment, soft cartilaginous crepitus, 
localized pain, swelling, and joint effusion. The separation may be 
compound or open injury. 

Treatment. — Reduction is accomplished by traction and manipu- 
lation. Immobilization is best obtained by a gypsum encasement, which 
should be split and held in place with a bandage, if there is danger of 
swelling. This should be continued for six to seven weeks and weight- 




FRACTURES OF THE TIBIA AND FIBULA 555 

"bearing allowed at the end of twelve weeks. Lateral contour splints of 
metal or felt or gypsum gauze may be used. 

Isolated separation of the upper |m 
epiphysis of the fibula has not been 
recognized. 

Fractures of the Shaft of the 
Tibia and Fibula. — Fractures of 
the bones of the leg occur in fre- 
quency next to fractures of the 
hones of the forearm. They take 
place at any time of life, are more 
frequent in the male sex, and in 
well-developed adults who lead an 
out-door life. The tibia actively 
supports the body; but the fibula 
acts in a supplementary manner 
and of itself cannot support the 
body weight. Hence it is that in 
fractures of the tibia by indirect 
force there is generally in addition 
a fracture of the fibula. Fractures 
of both bones are most frequent in 
the middle third of the diaphysis 
Plagemann's statistics show 92 
fractures of the diaphysis. Of 
these there were only 5 of the up- 
per third, 54 of the middle third. 
and 33 of the lower third of the 
shaft. The line of fracture in these 
lesions was approximately at the 
same level in both bones 34 times ; 
in 24 instances the line of fracture 
was higher in the fibula than in 
the tibia, and in 34 instances it 
was lower in the fibula than in 
the tibia. 

Etiology. — Fractures of both 
bones of the leg may be due to 
direct force, such as a kick, a blow, 
the weight of a falling object, or t 
by being run over. They may also FlG 733 
be the result of indirect force, as 
falls from a height, or accidents in which there is torsion or infraction 
of the leg with the foot held fast. Fractures by compression or mus- 






PlC. 73I.— Oblique fracture of the shaft of the tibia with a double fracture of the shaft of the fibu 

FlG. 737.— Oblique fractures of the shafts of the tibia and fibula; considerable overriding of the 

fragments. 




.38.— Spiral fracture of the shaft (1 
5. 739.— I 
Fig. 740 



) of the tibi 
fibula. 
Fin. 739- — Double spiral fracture of the shaft of the 



th spiral fracture of the shaft (high) of the 
: of the tibia. 
Fig. 741- 





/ 







PlC. 744— Oblique fracture of the shafts of the tibia and fibula. Union has occurred with laterat 

displacement and overriding. 
Fics. 74S AND 746.— Incomplete fracture of the shaft of the tibia in a bny aRed 12 years. Antero- 
posterior and lateral views. 



FRACTURES OF THE TIBIA AND FIBULA 



559 



cular action are unusual. Fractures by indirect force usually involve 
the lower portion of the middle third or the lower third of the shaft. 
Fractures by direct violence are not confined to any portion of the 
shaft. 

Varieties. — The line of fracture (Figs. 733-748) of the tibia may 
be transverse, oblique, V-shaped, spiral, or comminuted, and the frac- 
ture closed or open. Transverse fracture lines are unusual, and when 
seen are generally due to direct violence. The edges are usually ser- 
rated, and at times a three-cornered piece is detached from one or the 
other fragment. The usual form of fracture line is oblique, generally 
with the line of fracture running downward, forward and inward, so 




For legend for Figure 746 see Figure 745. 

Figs. 747 and 748. — Oblique fracture of the shaft of the tibia; boy aged 5 years. Anteroposterior 

and lateral views. 

that the lower end of the upper fragment presents beneath the skin of 
the inner leg surface as a sharp fragment; at times this fragment per- 
forates the skin. Torsion or spiral fractures are more common in the 
lower half of the shaft, are occasionally characterized by the separation 
of a triangular spiral portion of one of the fragments, and are often 
comminuted. Fractures by indirect violence are often open. This is 
due to perforation of the skin by sharp fragments. Fractures by 
direct force are occasionally open, due to either the fracturing force or 
to the development secondarily of pressure necrosis of the overlying 
soft parts. 

Displacement of Fragments. — The tendency in all fractures of 



5150 



TREATISE ON FRACTURES 



the shaft of both bones of the leg is toward lateral and over-riding 
displacement (Figs. 749-751). It is less frequent in the transverse 
fracture, but even there it may frequently be present. In oblique, 
spiral, comminuted and multiple fractures, over-riding of fragments 




Fig. 749. — Tibia and fibula (Left). Fracture of both bones below middle. Firm union with con- 
siderable displacement. The lines of fracture were oblique in both cases, passing from the crest in 
front downward and backward. There i-; a decided concavity anteriorly with considerable shortening. 
(Mutter Museum. Xo. 1427.67.) 

Fig. 750. — Tibia and Fibula (Right). Fracture of both bones. Union. The plane of fracture 

the fibular side of the tibia from a point 13 cm. above the ankle-joint, passes downward to a 

point on the inner side 6 cm. from the malleolus. In the fibula the plane passes from a point in the 

anterior surface 4 cm. below the styloid process to a point in the posterior surface 10 cm. below that 

process. (Mutter Museum. Xo. 1427.55.) 

Fig. 751. — Drawing to show the characteristic displacement of fragments in oblique fractures 
of the shaft of the tibia and fibula. (.1) quadriceps muscle; (B) femur; (C) patella; (D) tibia; 
(/•.) fibula. 



is the rule. The over-riding, lateral, or anteroposterior displacement 
is due to the fracturing force, the weight of the body, or muscular 
contraction. The usual displacement is upward, backward and out- 
ward of the upper end of the lower fragment. In addition there is 



FRACTURES OF THE TIBIA AND FIBULA 



561 



over-riding, angulation at the seat of fracture, and outward rotation 
of the lower fragment. 

Symptoms. — The usual symptoms of fracture of the shaft of the 
tibia and fibula are inability to use the legs as far as weight-bearing is 
concerned. While there may be cases in which the patient is said to 
have walked, it is only likely in incomplete fractures, or comminuted 
fractures of the tibia alone. When both bones are broken and frac- 




nd crepitus in fracture of the shafts of the 



ture is complete, attempts at lifting the leg from the bed will show angu- 
lation at the seat of fracture, deformity, axial deviation of the frag- 
ments, and outward rotation of the foot. Palpation along the crest of 
the tibia and its inner surface, which can usually be palpated beneath 
the thin overlying soft parts, will determine the seat of fracture of 
the tibia as well as the direction and degree of displacement, unless 
such a time has elapsed since the accident that considerable swelling 




alleolus of the tibia 



of the soft parts has occurred. Fracture of the fibula may also be 
determined in its lower half by palpation and direct pressure. In 
addition to these symptoms there will be localized tenderness, pain, 
swelling of the soft parts, crepitus, preternatural mobility (Fig. 752) 
and shortening. The shortening may be determined by measuring 
from the inner tuberosity of the tibia to the tip of the internal mal- 
leolus (Fig. 753), and by comparison with uninjured leg. Late symp- 
toms are the formation of blebs, ecchymosis, cellulitis, and oedema. 
The appreciation of crepitus may be prevented by interposition of soft 



562 TREATISE ON FRACTURES 

parts or impaction of fragments. In doubtful cases rontgenograms 
should be taken in anteroposterior and lateral planes to determine 
accurately the seat and variety of fracture and the degree of displace- 
ment of fragments. 

Complications. — The complications seen in closed fractures of 
the tibia and fibula are injury to the anterior or posterior tibial or 
peroneal arteries, or the nutrient artery of the tibia, and rarely injury 
to the peroneal or tibial nerves. The complications of open fractures 
are sepsis, cellulitis, necrosis of fragments, and pressure necrosis of 
the overlying soft parts. 

Prognosis. — Union occurs in closed fractures of the tibia in from 
five to eight weeks and in the fibula in from four to six weeks. It 
depends in great measure upon the accuracy of reduction. Persistent 
displacement of fragments will delay union, and permanent interposi- 
tion of soft parts may result in pseudo-arthrosis. The usual fracture 
of bones of the leg treated by non-operative means results in satis- 
factory union without special deformity or disability if the surgeon 
has mechanical acumen, anatomical knowledge and surgical experi- 
ence, and gives attention to his patient. Displacement of fragments, 
prominence particularly of the lower end of the upper fragment, short- 
ening, axial deviation, and posterior angulation at the seat of fracture 
may readily occur under other circumstances (Fig. 754). In com- 
minuted fractures there may be excessive callus formation, shortening, 
and persistent local pain accentuated by weather changes. The pres- 
ence of some stiffness of the knee- and ankle-joints prolongs the time 
of convalescence, and is usually due to prolonged immobilization with- 
out massage and early mobility of these joints. In open fractures 
there is the possibility of suppuration developing here as elsewhere, 
unless sterilization of the wound is primarily effective. If it occurs, 
union is delayed, there may be necrosis of fragments, sinuses persist- 
ent for months, and the ultimate result a shortened leg with some 
degree of angular deformity, oedema of the soft parts, infiltration of 
the muscles, with atrophy and stiffness of the ankle-joint. These re- 
sults are unusual in the hands of well-equipped surgeons who have had 
a chance to treat the case from its beginning, and have taken advantage 
of their opportunities. Delayed union or pseudo-arthrosis often per- 
sists for a long time. 

Treatment. — The treatment to be adopted in fractures of the 
shaft depends upon the variety of fracture and possibility of obtain- 
ing anatomical apposition of fragments. In many fractures reduction 
should be promptly performed under general anaesthesia. Some delay 
may be warranted if shock be present to a marked degree. Reduction 
in closed fractures usually may be accomplished readily by strong, 
steady traction on the foot, counter-traction at the flexed knee, and 



FRACTURES OF THE TIBIA AND FIBULA 



5(33 



local manipulation of the fractured ends. Interposition of soft parts 
can generally be removed by this method, and anatomical coaptation 
of the fragments obtained. Usually there is comparatively little diffi- 
culty in maintaining this anatomical position. In transverse fractures 
and in a few oblique fractures it is possible to interlock the fragments 
into approximately their normal position. Other cases may show over- 
riding of fragments when traction and counter-traction are stopped. 
In the majority of cases it is comparatively easy to devise a suit- 
able apparatus to maintain the fragments in their normal position 
without producing undue pressure from -traction about the ankle. It 
is in these unusual cases that operation and direct fixation of the frag- 
ments by means of a bone inlay or a metal plate are advised. If the 




FlG. 754- — Drawing to show how shortening mav tnke place by posterior angulation (middle 
figure) of fragments, and by overriding of fragments (right-hand figure) (left-hand figure is normal for 
comparison). (Modified after Zuppinger.) 

non-operative form of treatment is used, the careless or inexperienced 
may expect a certain degree of shortening, over-riding and angulation 
of fragments with axial deviation. In the operative treatment there is a 
possibility of mild sepsis delaying union and cure and necessitating 
removal of the fixation plate, or of severe sepsis leading to amputation 
or death. Neither form of treatment is likely to be difficult in skilled 
hands. 

Non-operative Treatment.— The foot and leg should be cleaned 
with water and soap and alcohol, and after reduction should be tem- 
porarily immobilized in a pillow and side splints extending from the 
mid-thigh to below the foot. When maximum swelling has taken 
place this dressing should be removed, further attempts at reduction 
made, if deformity still exists, and the foot, leg and thigh immobilized 



564 



TREATISE OX FRACTURES 



in a gypsum case, which should be split down the front or on each side. 
In the use of a gypsum case, one should be careful to preserve the 
normal line of foot and leg: there should be no anteroposterior or 
lateral angulation at the seat of fracture. The foot should be at right 
angle to the leg and inverted, and the knee-joint included in the gypsum 
dressing. The case is split down both sides, forming an anterior and 
a posterior portion, or in front, so that the case may be removed 
from time to time, the seat of fracture inspected, angulation corrected. 




Fig. 755. — Method or ' ■- - ures of both bones of the leg in a swinging fracture box. The 

flexion of the knee may be altered without disturbing the fracture and the def - n changed 

when necessary. The patient can readily alter hjs position in bed and thus avoid bedsores over sacrum. 
The bed-pan is easily placed under the buttocks. The box should be opened daily 
and the leg examined, bathed and rearranged in the box. 

and frictions, massage and passive motions used. At the end of three 
or five weeks in average cases a new gypsum case may be applied and 
the patient allowed up on crutches. Weight-bearing may be encour- 
aged at the end of eight weeks, except in oblique or spiral or other- 
wise troublesome fractures. By raising the well foot with a thick-sole 
shoe, the patient may go alxjut on crutches very early in leg fractures. 
Early union is probably hastened by early dependant leg and exercise 
in open air on one'-; crutches. 

A swinging fracture box (Fig. ?$?) for ten days or two weeks 



FRACTURES OF THE TIBIA AND FIBULA 



565 



with frequent inspection, massage and mobility, followed by a gypsum 
case, may be used. This method is very often a preferable one. By 
fastening a rope and weight to the foot board of the fracture-box and 




Fig. 756a. — The modified Zuppinger traction apparatus for treating fractures of both bones of the leg. 




having the box to slide on a smooth wooden surface placed on the bed, 
traction may be added in rebellious fractures. The fracture-box in 
this method of dressing leg fractures must not be suspended. Tenotomy 



566 



TREATISE ON FRACTURES 




g Is" 




FRACTURES OF THE TIBIA AND FIBULA 



567 







568 TREATISE OX FRACTURES 

of the tendon of the calf muscles at the heel will often relieve displace- 
ment caused by gastrocnemius spasm. In ordinary cases the flexion of 
the knee by swinging the box splint relaxes this muscle enough. 

When there is a marked tendency to recurrence of deformity after 
attempts at reduction and operative measures are contraindicated. 
traction upon the lower fragment may be made with the hip and knee 
flexed, using the modified Zuppinger apparatus (Fig. J?6). When 
there is no tendency to displacement of fragments, a convenient form 
of dressing is the Cabot posterior and side splints. 

Operative Treatment | Figs. 757-770). — When it is found impos- 




— 1 - - 

: 

sible to maintain anatomical apposition of fragments as proved by in- 
■n and confirmed by radiograph, which is unusual, and there are 
no contraindications to operation, it is proper to operate and retain the 
fragments in their normal position by a bone inlay or by a metal plate. 
This is seldom necessary in the usual fractures. Care should lie taken 
after the application of the plate to continue traction and prevent 
angulation at the seat oi fracture until the wound is closed, and a 
sterile dressing and gypsum case applied. In operative cases treated 
by metallic fixation, the time for union i> a little longer than when the 
fragments are correctly apposed and treated without operation for 
direct fixation. The after-treatment is the same as that given under 



FRACTURES OF THE TIBIA AND FIBULA 569 





Figs. 767 and 768. — Transverse fracture of the tibia with incomplete fracture of the fibula 
Baseball plaver injured sliding into second base. Failure of reduction of fragments by non-operativ 
5. (See Figs. 769 and 770.) 





Figs. 769 and 770. — Transverse fracture of the tibia and incomplete fracture of the fibula. 
Reduction by operative means and fixation of tibial fragments by Sherman plate. (See Figs. 767 and 
768.) (Courtesy of Dr. J. M. Spellissy.) 



non-operative treatment. The plate is to be buried under the muscles 
on the outer side of the shaft, according to Lane's technic, who leaves 
it indefinitely in the tissues. It would seem likely that a superficial plate 



570 



TREATISE ON FRACTURES 



on the subcutaneous surface of the bone would answer as well for fixa- 
tion, and always be easily removed by incision after its usefulness had 
ended. 

Open Fractures. — In infected open fractures, the principal objects 
are to control hemorrhage and primarily to render the wound aseptic, 
for the details of which treatment the reader should consult the para- 
graphs on general treatment of open fractures. 




Fig. 771. — Photograph sho 



ng a result often obtained in badly comminuted 
bones of the leg followed by suppuration. 



fractures of the 



Open cases may be treated on a posterior Cabot or wooden splint 
with foot-piece, and by using side splints or a divided gypsum case 
extending above and below the seat of fracture. 

It is in the opinion of one of the authors proper to treat infected 
open fractures by the fracture-box and gypsum splint, as are closed 
fractures. The primary care of the wound if successful will permit it 
to rapidly heal and the fracture box may then be superseded by the 
gypsum encasement. If the wound suppurates the fracture box may 



FRACTURES OF THE TIBIA AND FIBULA 571 




572 



TREATISE ON FRACTURES 



be used for a longer period and the gypsum case, which is then sub- 
stituted, may have an opening like a window cut in for inspection and 
dressing of the wound. Drainage is important in bad infections. 

The report of the Committee on Fractures of the British Medical 
Association shows that in closed fractures of both bones the per- 

Fig. 776. Fig. 777. 





Fig. 776. — Comminuted fracture of the shaft of the fibula. Direct violence. 
Fig. 777. — Oblique fracture of the shaft of the fibula. 

centage of good anatomical and functional results by non-operative 
means was 44.4 and by operative means 63.6; that good functional 
results with poor anatomical results were obtained in 70 per cent, by 
non-operative means and 68.1 per cent, by operative measures, while 
in fractures of the tibia alone the percentage was, respectively, 74.4 and 
76.4. The improvement in treatment of isolated tibial fractures is due 
in a great measure to the intact fibula acting as a splint for the tibia. 

The poor results found in the non-operative treatment by this Com- 
mittee is believed by one of the authors to be largely due to prolonged 
immobilization, infrequent inspection, and negligence of early mild 
massage and mobility, so frequent in British surgery until Lane's 



FRACTURES OF THE TIBIA AND FIBULA 



573 



propaganda for operative treatment caused scientific non-operative 
treatment to be more usual. The Reports of the Committee of the 
American Surgical Association for 1913-14— 15, etc., will be found of 
interest in this connection. 

Isolated Fractures of the Shaft of the Tibia. — Plagemann's 
Rostock statistics based' on 1393 fractures show isolated fractures of 
the shaft of the tibia in 24 cases (1.79 per cent.) and of the fibula 30 
cases (2.15 per cent.). 

Isolated fractures of the shaft of the tibia are rare (Figs. 772- 
775). When the tibia is broken by direct violence the fibula may 

Fig. 778. Fig. 779. 





Fig. 778. — Supramalleolar fractures of the tibia and fibula. 
Fig. 779. — Supramalleolar fracture of the tibia. 

escape injury, but often it is also broken; when the fracture of the 
tibia is due to indirect violence, the weak fibula is unable to sustain the 
weight of the body thrown upon it and is also fractured. 

Symptoms. — The symptoms of isolated fracture of the tibia are 
similar to those of fracture of both bones of the leg, but have certain 
modifications. The patient may be able to bear some weight on the leg 
if the fracture line is transverse and the fragments interlocked. There 
is only moderate mobility of fragments, slight over-riding, crepitus, 
localized pain, tenderness and swelling but not so much deformity, and 
axial rotation of the lower fragment. The sound fibula tends to act 
as a splint for the fractured tibia. 

Treatment. — As there is not such a tendency to over-riding and 



574 



TREATISE ON FRACTURES 




\ 



^Jk 





\ 



FRACTURES OF THE TIBIA AND FIBULA 



575 



deformity as is seen when both bones are broken, ordinary non-opera- 
tive measures will more often give a good anatomical and functional 
result. The treatment is the same as given above for fracture of both 
bones. Weight-bearing in walking need not be postponed so long as in 
fracture of both bones of the leg. In spiral and oblique fractures in 
this region, it may occasionally be found necessary to operate and 
directly fix the fragments. 

Isolated Fracture of the Shaft of the Fibula (Figs. 776 and 777). — 
This injury is generally caused by direct 
violence. 

Symptoms. — There is little if any tend- 
ency toward displacement of fragments on 
account of the firm attachment of muscular 
structures. Over-riding, axial displacement 
and angulation are extremely rare. There 
may at times be some lateral displacement 
inward of the upper end of the lower frag- 
ment. The chief symptoms are localized 
tenderness, pain on direct pressure, and 
on forcing the shaft of the two bones to- 
gether crepitus may be demonstrated. Lo- 
cally there is generally some bruising of the 
soft parts, swelling, and later ecchymosis. 
Walking is often possible but generally at- 
tended by considerable pain. 

Treatment. — As there is little displace- 
ment of fragments, all indications for treat- 
ment are met by immobilization in a gypsum 
splint extending from the toes to just below 
or a little above the knee. This dressing- 
should be used for from three to five weeks 
and be followed by a bandage. Weight-bear- 
ing may be begun at the fifth to sixth week. 
Fractures of Lower End of the Tibia and 

/t^a 7 i 3 „ZlbTa am otr q u"fracturl F^ula. — SUPRAMALLEOLAR FRACTURES 

rbXlilr^^r 1 ^ ^ (Figs. 778-783) --This class includes all 
inward?t d orpo^ 3 ^°cm W above a the breaks occurring within the lower one and 
apex. (Mutter MuseumNo. 1427.81). a ha if to two j nc h es f t h e lower end of the 

tibia. Many of them are extra-articular, while a fair proportion involve 
the tibiotarsal joint. Comminution of fragments is fairly constant. 

Statistics. — Plagemann's statistics show 22 cases of fracture. In 
13 instances the fractures were extra-articular; and of these the 
fracture line was transverse 6 times, oblique in 2 cases, spiral 3 times, 
and in 2 cases there was a transverse fracture with a breaking off of a 




576 TREATISE ON FRACTURES 

three-cornered piece of bone. In 7 cases the line of fracture extended 
into the ankle-joint, and of these 4 were classified as T- or Y-fractures 
and 3 as severe comminuted fractures : in 2 cases there was found a 
transverse fracture of the internal malleolus. The fibula was 11 
times fractured approximately at the same level, 8 times in the external 
malleolus : twice there was a double fracture of the fibula, in one case 
involving the lower third of the shaft and external malleolus, and in the 
other the neck of the fibula and the external malleolus. 

Etiology. — These fractures may be the result of direct violence 
as in severe blows above the ankle, and run-over accidents, but as a 
rule they result from indirect force, as in falls from a height, with the 
patient landing on his foot in an inverted or everted position. The 
result is a fracture, above the malleoli, transverse, oblique, spiral, or 
longitudinal in character. An accompanying fracture of the fibula is 
usually present. 

Symptoms. — In fractures not involving the joint the symptoms are 
more or less similar to those of fracture of both bones in the lower 
third of the shaft. Usually there is marked swelling of the entire 
lower leg, pain, ecchymosis, deformity, undue mobility, lateral or 
posterior displacement of the foot and lower fragment, crepitus, and 
inability to bear Aveight on the foot. In fractures involving the joint 
there is, in addition, widening of the ankle-joint; and there may be 
displacement upward of the astragalus between the fragments into 
the interosseous space. 

Diagnosis. — The condition should be carefully differentiated from 
dislocation of the foot, fracture of lower third of shaft, and fracture of 
the lower part of the fibula with posterior dislocation of the foot. 

Prognosis. — The prognosis for a good result without deformity 
and without restriction of the motion at the ankle-joint is particularly 
grave when the fracture is comminuted or involves the ankle-joint. 
Even in cases which do not involve the ankle-joint, impairment of mo- 
tion and deformity are frequent ; but this defect may usually be averted 
by careful attention to reduction and sufficient solicitude about maintain- 
ing the integrity of the soft tissues by massage and early mobility. 

Treatment. — Treatment consists in reduction of fragments by trac- 
tion and manipulation, immobilization for one week or more in pillow 
and side splints or a swinging fracture-box and later in a gypsum case. 
Care should be taken to secure as nearly normal apposition of frag- 
ments as is possible and to correct all external deformity. Immobiliza- 
tion should be continued for at least six to eight weeks, but at the end 
of two or three weeks or earlier careful massage and passive motion may 
be given. Weight-bearing may begin about the end of the tenth or fif- 
teenth week, varying with the line of fracture and the weight and work 
of the patient. A high sole on uninjured side with crutches a few weeks 



FRACTURES OF THE TIBIA AND FIBULA 577 





Fig. 785. — Separation of the 



TREATISE OM FRACTURES 

longer is better surgery than hasty ambulation with resulting bending 
i: :>.= sea: : : ;-re^-:. I: -"is :he ':i L :"r:/.i"i:il rrfiis in --he 5 = :ri;-..:7e? 
that caused Lane to examine London policemen and other constant 
walkers, who had sustained ankle fractures. He found bad final results 
with grave disabilities. In many the axis of the limb was permanently 
altered with resultant change in the bearing of the articular planes on 
one another. Even after unassisted walking is allowed a high-laced shoe 
or boot is a desirable support to the ankle for some months. This 
offers protection against sudden misstep. 

Separation and Fracture of the Lower Epiphysis (Figs. 784— 
786). — Complete separation of the lower epiphyses of tibia and fibula is 
an extremely rare injury. The lesion which is most frequently observed 
is not a complete separation, but a fracture through the tibial epiphysis 
with a tearing off of a small portion of the diaphysis. The line of 
fracture through the diaphysis is a high fracture through the internal 
malleolus and through the internal and anterior portion of the 
diaphysis. These injuries are observed before the twentieth year. 

Etiology. — The cause of these fractures is either marked forcible 
eversion or inversion of the foot, as in jumping or in falls from a 
height 

Symptoms. — Displacement of fragments is usually very slight 
The usual symptoms are those of an acute synovitis of the ankle- 
joint, or a sprain, and in addition localized pain on motion, tenderness 
on pressure over the epiphyseal line, and at times cartilaginous crepitus. 

Treatment — In the absence of displacement of fragments the 
treatment consists in immobilization in a gypsum case for four weeks, 
after which time the patient may be allowed to use the leg with the 
ankle region supported by adhesive plaster strapping. 

Malleolar Fractures 

Fracture by Eversion and by Abduction. — The term Pott's fracture 
is erroneously given by the majority of physicians to all fractures oc- 
curring about the ankle-joint This is a mistake. The lesion described 
by Percival Pott is a fracture of the fibula not higher than two to two 
and a quarter inches above the tip of the external malleolus, which is 
the weakest point of the fibula and just above the tibiofibular ligament. 
a rupture of the internal lateral ligament accompanied by outward 
dislocation of the foot The term as now used includes cases in which 
there is a tear- or strain- fracture of the internal malleolus instead of a 
mere rupture of the internal lateral ligament The name Pott's fract- 
ure should be dropped and the descriptive anatomical term employed. 

Etiology. — Indirect violence is the cause of the majority of these 
fractures. The injury is the result of a combination of factors — 
usually eversion of the foot, rotation about its long axis, and abduction 



580 



TREATISE OX FRACTURES 



from the vertical axis of the leg. It is liable to occur when the foot is 
firmly held, and the body forced outward by violent rotation of the 
leg when the foot is fixed, and by falls upon the foot when it is everted 
or abducted. 

Mechanism of Fractures. — The mechanism of the fracture is ex- 
plained as the resultant of two forces — pressure and traction (Figs. 7S7 
and 788). In falls outward with the foot fixed, eversion and abduction 
of the foot are produced, the internal lateral ligament is stretched, 

and, as it rarely ruptures, the force 
tears off the internal malleolus, gen- 
erally at its base; as the force con- 
tinues the astragalus is forced 
against the external malleolus, fix- 
ing the latter, at the same time the 
weight of the body falling outward 
carries with it the leg and the fibula ; 
the fibula is checked by the astra- 
galus and kept attached to the tibia 
by the tibiofibular ligament; either 
the latter ruptures or a line of frac- 
ture occurs at the weakest point of 
the fibula just above the point of at- 
tachment of the tibiofibular liga- 
ment. It is here that the fixed por- 
tion of the fibula meets the potential 
moving upper portion, and fracture 
occurs about two to two and a quar- 
ter inches above the malleolus. The 
line of fracture of the fibula depends 
to a great extent upon whether the 
fall is directly outward or whether 
some torsion of the tibiotarsal joint 
occurs at the moment of fracture. 
Another result of this mechanism 
may be fracture of the internal mal- 
leolus, as above described, with fracture of the external malleolus just 
above the level of the tibiotarsal joint by outward pressure of the 
astragalus. 

Displacement (Figs. 789-793). — In typical cases the line of frac- 
ture of the fibula is oblique or spiral in character and is situated 
within the lower two and a quarter inches of the lower end of that 
bone. The foot is usually rotated outward and later abducted. When 
this displacement takes place the upper end of the lower fragment is 
displaced inward and the external malleolus outward : when there is 




Fig. 787. — Drawing to show the normal struc- 
tures of the ank!e-joint. a, tibia; 6, astragalus; 
c. internal lateral ligaments; d, interosseous 
ligament; e. calcaneum ; /. fibula: g. posterior 
fasciculus and h. middle fasciculus of external 
ligament: and i, interosseous or tibia-fibular 
ligament. 



FRACTURES OF THE TIBIA AND FIBULA 



581 



considerable tearing across the anterior capsule of the joint, there is 
generally posterior dislocation of the entire foot with accompanying 
displacement of the fibular fragment. When there is, in addition, 
fracture of the tibial malleolus instead of simple tearing of the in- 
ternal lateral ligament, the line of break is generally transverse across 
the base of the malleolus and the separated fragment is displaced out- 
ward with the astragalus, and posteriorly if the latter is so displaced. 
There occurs a variety of this fracture in which the fibula is broken 
above or through its malleolus and the tibia fracture by a line running 
oblique upward and outward from the articular surface of the lower 
end of the tibia. In this injury the break of the tibia is perhaps often 




Fig. 788. — Drawing to show the most common types of fracture about the ankle-joint, made after 
Rontgenograms (Figs. 789, 790 and 802) and methods of reduction of these types of fractures. A, 
fracture of fibula with rupture of the internal lateral and tibio-fibular ligaments; B. fracture of the 
fibula with fracture of the internal malleolus, and C. fracture of the external and internal malleolus. 
Figs. A and B are types of the classic Pott's fracture by eversion and abduction of the foot and Fig. C 
is of the reversed Pott's fracture by inversion and adduction of the foot. The arrow in each figure 
shows the direction of force necessary to reduce these fractures. 

overlooked. It is liable to permit marked displacement of the foot 
backward, and may be mistaken for a backward luxation of the tarsus 
at the astragalotibial joint. 

Symptoms. — All of these cases are not characterized by deformity 
when seen by the surgeon, for in many the deformity has been reduced 
by a friend pulling upon the foot. The most notable symptoms are 
generalized swelling about the ankle, localized on the inner side about 
the tip of the internal malleolus and on the outer side localized not at 
the tip of the fibular malleolus but somewhat above the malleolus. 
There is localized pain which is increased on attempts at Avalking. 
Palpation reveals tenderness on pressure and crepitus about two inches 



582 



TREATISE ON FRACTURES 



above the tip of the external malleolus (Fig. 793) with moderate 
angulation of fragments; and over the internal malleolus there may be 
felt the sharp edge of the tibia from which the internal malleolus has 
been torn. This is particularly noticeable if external lateral displace- 
ment of the foot is made. Crepitus may also at times be detected over 
the internal malleolus. When the lesion is a mere rupture of internal 
lateral ligament and not a fracture of the internal malleolus, no 
crepitus is discoverable in this region. By grasping the leg with one 
hand and the foot with the other, abnormal lateral mobility of the foot 
r . ~*n in the mortice of the ankle-joint 

|T*fNN68f nia }' ' >e °' jta i ne d in some case 
(Fig. 794). 

When there is displacement of 
the foot, it will be noticed that 
the foot is slightly abducted and 
everted in the valgus position. A 
line drawn through the long axis 
of the tibia normally is prolonged 
between the first and second toes ; 
but, in the presence of this dis- 
placement of the foot, it falls to 
the inner side of the foot. There 
is also prominence of the upper 
fragment of the tibia at the region 

/of the internal malleolus and ap- 
parent broadening of the ankle- 
joint. On the outer side of the 
ankle-point there is angular de- 
formity corresponding to the 
fracture of the fibula. 

If there has occurred marked 
laceration of the anterior and posterior portions of the joint capsule. 
a posterior as well as an outward displacement of the foot may be 
present. This may be determined by comparison of the lateral as- 
pects of the injured leg and foot with the sound side by palpation; 
it will be noticed that the lower articular edge of the tibia may be 
felt at the ankle, and by grasping the foot and leg with the two hands 
it is possible to demonstrate the dislocation by pulling the foot for- 
ward on the leg. In all cases radiograms should be made in antero- 
posterior and planes not only to determine the variety of fracture. 
but also the amount of displacement of fragments. The supra- 
malleolar fracture of the fibula with fracture of the lower end of 
the tibia, without its line involving the tibial malleolus at all, but run- 
ning into the astragalotibial joint, has been called by some the 




FRACTURES OF THE TIBIA AND FIBULA 583 



{ V§ 


^ 1 


I.' 

• t j 

i 
i 



Fig. 790. — Fracture of the fibula with fracture of the internal malleolus, anteroposterior and lateral 




. :.-_..-. ~-n : .- :- .-. rnsES 



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~r~,\.~~z z ::■ "' i- ' zz z>' -z&z. "' -~ , : i' *■■'?< inii ;_~ 7 ~"\_"~.l. ;c an~ 

? \."'7 7" ; ~. S'Z ' ..'': '. Z '.'-. ~.~~.~~\.. ".!__-:'"-—: ~ ZZ1 -" T*~- :'• i^'i"" 

"i: : . - _ ' ■ : . " - ' :'-"""'._'-' IT; 

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' ■"•".: \'~ z - izi~~iz ' '_ : "." t z zzzzzz :. : : ._ t 

. . : z -Z~ . :i~zz.t.zzz.z ~_:7 ir:g^.c&^ 

■■■ 





i 



pEanradL WBoenn tfire - - - 

LI' ._" ' " . i 

- 

'. ' ' -1 L~'l ~'>:_.L 1" "■>: 1.-..J7. --.7-": -■.•• 17 



FRACTURES OF THE TIBIA AND FIBULA 



585 



with efficient control of its anatomical relations until union takes place. 
In all but the cases with little or no displacement, reduction should be 
performed immediately after the diagnosis is made, and is best ob- 
tained with the aid of general anaesthesia. There are three movements 
necessary in making perfect reduction : The foot must be carried for- 
ward to overcome posterior dislocation, and inward in order to bring 




Fig. 793.— Method of determining 




Fig. 794. — Method of determining lateral mobility of the ankle-joint in fractures of the malleoli. 



the base of the tip of the internal malleolus to its proper site on the 
tibia and to correct outward displacement of the astragalus and that 
of the lower fragment of the fibula ; and slight inversion made to relax 
the tension of the internal lateral ligament on the internal malleolus 
and to prevent subsequent valgus deformity (Fig. 795). To do this 
one should grasp the leg firmly, with one hand above the ankle on the 
inner side and with the other hand seize the heel and foot ; then pull 



580 TREATISE ON FRACTURES 

the latter forward, push it inward, and at the same time pull the leg 
outward. This procedure will thoroughly reduce the fragments and 
bring them into their normal relations. The foot and leg are then 
placed in a pillow and side splints up to the knee and held in this dress- 
ing until maximum swelling has ceased, which is about three to four 
days (Fig. 796). A suspended fracture-box is an exceedingly valuable 
dressing in fractures at the ankle. It is greatly preferred by one of the 
authors to other means of support for the first two weeks. 



Fig. 793. — Method of reduction of classic Pott's fracture by forced inversion of the foot and correction 
of posterior displacement if it is present. 




ition of a pillow and side splints for temporary immobilization of fragments 
and leg in a gypsum case. This form of immobilization should be used until 
the maximum swelling begins to disappear. 

If a primary radiograph has not been taken, one should now be 
made in two planes if possible. Tf anatomical apposition of fragments is 
known to be present, the foot and leg are placed in a gypsum case, ex- 
tending from the toes to just below the knee. In applying this case care 
should be taken to maintain the fragments in their normal position, the 
fool should be held at right angle to the leg and in a position of slight in- 
version (Fig. 797). The case should be split down each side, making 



FRACTURES OF THE TIBIA AND FIBULA 587 

an anterior and a posterior portion so that frequent observations may 
be made, or a single split down the front may be used to enable the 
surgeon to remove it every day or two. At the end of two and a half 
weeks a second case should be applied, the patient allowed on crutches, 
and at the end of from five to seven weeks the case may be discarded 
and an adhesive plaster dressing used, for maintaining support to the 
healing fracture. Weight-bearing should not be permitted until the 
end of eight or nine weeks on account of the possibility of distortion 
of the ankle due to soft callus. Careful massage and passive motion 
should be instituted from an early period. Some surgeons believe not 
till the end of the fourth week. Others believe it better to begin 
cautiously a few clays after the receipt of injury. The longitudinal arch 



n 



Fig. 797. — Method of holding the foot and leg while a gypsum case is being applied. The foot should 
be slightly inverted, held at right angles to the leg and the leg supported by a sand bag as shown. 

of the foot should be maintained in ankle fractures and the length of 
the dorsum restored by complete reduction of posterior displacement of 
the tarsal fragments of the tibia and fibula. 

After-results. — Good results should follow proper reduction and 
the maintenance of accurate apposition of fragments. Unfortunately, 
these cases are often improperly reduced, carelessly observed, and it 
is only when convalescence should be established that deformity is 
noticed. Convalescence is often prolonged by persistent oedema, stiff- 
ness of the joint, and atrophy of muscles due to prolonged fixation. 
Haenel's statistics, quoted by von Bergmann, based on 40 cases, show 
28 recovered (70 per cent.) ; 12 became disabled (30 per cent.) and 
the average loss of ensuing efficiency was about 50 per cent. These 
fractures, like fractures of the lower end of the radius, are often mis- 



588 



TREATISE ON FRACTURES 



understood and badly treated. Good surgery will, in many cases, prove 
its value by obtaining practically ideal results in function as well as in 
contour by non-operative means. 

Fracture of Fibular Malleolus with Fracture of the Posterior 
Articular Edge of the Tibia (Figs. 798-799). — This injury is no doubt 
a variation of the typical fracture of the external malleolar region. It 
consists of a supramalleolar fracture of the fibula, usually about one 
and a half to two inches above the tip of the malleolus, with fracture 
of the tibial malleolus and posterior articular surface of the tibia. 

Etiology. — The etiology of the fracture is the same as that of the 




FtG. 798. — Fracture of the fibular malleolus with fracture of the internal malleolus and posterior arti 
ular edge of the tibia. Posterior displacement of the foot; anteroposterior and lateral views. 



typical fracture just described, but in addition there is visually some 
plantar flexion of the foot. 

Mechanism. — In addition to the usual mechanism of fracture of 
the fibular malleolus, the trochlear surface of the astragalus is forced 
against the posterior edge of the tibial articulating surface and a frag- 
ment, usually consisting of the internal malleolus and posterior edge, 
is broken aii. Two fragments, one consisting of the internal mal- 
leolus and the other of the posterior articulating edge of the tibia, 
may be occasionally broken off. This condition is the exception. The 
anterior portion of the joint capsule is ruptured and the foot is not only 
dislocated inwardly, but also posteriorly, and usually is drawn upward 
by the calf muscles, so that in some instances the remaining articular 
surface of the tibia i- displaced anteriorly to the trochlear surface of 



FRACTURES OF THE TIBIA AND FIBULA 



589 



the astragalus and rests upon the head of the latter, with consequent 
shortening of the leg. 

Symptoms. — In addition to the usual symptoms of external mal- 
leolar fracture, there is marked dislocation backward of the foot. 
With this posterior displacement, there is a marked tendency for re- 
currence and there can be felt anteriorly the prominence of the an- 
terior edge of the articulating surface; in some cases there may be 
distinct dislocation in addition to the fracture. Measurement from 
the inner tuberosity of the tibia to the tuberosity of the scaphoid will 



Fig. 799. 




Fig. 799. — Fracture of the fibular malleolus, 
the tibia. Posterior displacement of the foot. Nc 
ulating surface of the tibia and evident shortening c 
of the foot. 

Fig. 8oo. — Fracture of the fibula, of the internal 
the 



iternal malleolus and posterior articular edge of 
: the prominence of the anterior edge of the artic- 
the leg, due to upward and posterior displacement 

lalleolus and of the external articulating edge of 



show shortening as compared with the other side. A radiographic 
examination should be made if practicable. The differential diagnosis 
from the usual fracture can ordinarily be made upon the tendency to 
prompt posterior and upward dislocation of the foot upon relaxing 
one's anterior pull of the foot. 

Prognosis. — This depends in great measure upon primary recog- 
nition of the condition, and efficient treatment. Owing to involvement 
of the supporting surface of the tibia, there will be a more prolonged 
convalescence and lessened function as compared with the usual frac- 
ture in the malleolar. 



590 TREATISE ON FRACTURES 

Treatment. — Owing to the liability to recurrence of displacement of 
fragments after reduction, it is advisable to immobilize the foot and leg- 
in a fracture-box after reduction and later to use a gypsum dressing, 
preferably a gypsum case, from the toes to the knee. Reduction should 
be performed under general anaesthesia. In addition to the method of 
reduction described under the treatment of malleolar fracture, the foot 
should be carried also into a position of dorsal flexion. After the 
application of the gypsum case it should be split so as to form two 
splints, or a fracture-box should be so used as not to cause too great 
constriction and to allow daily inspection. The accuracy of anatomical 
reposition of fragments should be gauged by the radiogram or by fre- 
quent inspection. Flexion of the knee in a swinging fracture-box, and 
even subcutaneous section of the tendon of Achilles, may be required 
to prevent recurrent displacement of the foot backward. Traction on 
the foot by means of a plantar footboard and pulley extension may be 
needed. Steinmann's nail traction from the heel may be used. Weight- 
bearing should be postponed for ten to fifteen weeks in severe cases or 
in heavy patients and then very cautiously permitted. 

Fracture of Fibula with Fracture of External Articular Edge of 
Tibia (Fig. 800). — This is a rare fracture and must be considered as 
a variant of the fracture by eversion and abduction. 

Etiology. — This lesion generally is due to a fall from a height in 
which there is an eversion and abduction of the foot. The weight of 
the body is of chief importance in its production. 

Mechanism. — In addition to the mechanism described above under 
fibular fracture, there is the effect due to the weight of the body 
being applied simultaneously with the violence causing the supramal- 
leolar fracture of the fibula; by this force the outer trochlear surface 
of the astragalus is carried sharply against the outer portion of the 
articular surface of the tibia, by external rotation and abduction of the 
foot, so that either the tibiofibular ligament must give way or the outer 
edge of the tibia be broken away from the shaft. Dislocation upward 
of the astragalus between the tibia and fibula may occur. 

Symptoms. — The symptoms of this fracture are those of a simple 
fibular fracture with, in addition, an unusual widening of the joint. 
This widening is due to the separation of the tibia from the fibula when 
there is rupture of the tibiofibular ligament, or separation of the outer 
tibial fragment from the remaining portion of the lower end of the 
tibia. Accurate diagnosis usually requires a radiographic examination 

Prognosis. — The recovery of good function will depend entirely 
upon the completeness of reduction and the maintenance of accurate 
apposition of fragments until union is firm. 

Treatment. — On account of the possibility of upward and pos- 
terior displacement of the astragalus between the tibia and fibula, the 



FRACTURES OF THE TIBIA AND FIBULA 591 

primary retention of the leg and foot in a pillow and side splints after 
reduction is not advocated. General anaesthesia should be used for 
reduction, which is to be accomplished as in the usual fibular fracture. 
Subsequently immobilization should be secured by a gypsum case ap- 
plied from the toes to just below the knee. The plaster-of-Paris en- 
casement should be immediately split into anterior and posterior 
portions. 

Immobilization should last for at least six weeks and weight-bear- 
ing be allowed only cautiously at the end of about nine weeks. A swing- 
ing fracture-box for ten days or two weeks, followed by a circular 
gypsum encasement, is exceedingly satisfactory. Section of the tendon 
of Achilles may be used to prevent the displacing influence of gastroc- 
nemius spasm. 

Inverted Pott's Fracture or Fracture of the Fibula by Inversion 
and Adduction (Figs. 801 to 804). — This variety is not as common as 
fracture by eversion and abduction. 

Etiology. — The fracture is the result of indirect violence, and usu- 
ally is due to a fall with the foot in a position of inversion or adduction. 
It occurs in mis-steps, in jumping, and in sudden force applied to the 
outside of the leg when the foot is fixed". 

Mechanism. — Potentially this particular fracture should be fre- 
quent, because often one makes a mis-step, the foot is inverted, and one 
feels a sharp, sudden strain at the point of attachment of the external 
lateral ligament. When fracture occurs there is a tear-fracture of the 
external malleolus and a pressure fracture of the internal malleolus 
due to forced inversion of the astragalus against the tibial malleolus. 
The line of fracture of the external malleolus is lower than that seen 
in the true fibular fracture with eversion, being usually transverse or 
slightly oblique, and occurring in a line continuous with the articular 
surface of the tibia; the line of fracture in the internal malleolus is 
higher than that seen in the eversion fracture, being triangular in shape 
and running from the lower articular surface of the tibia upward and 
inward. At times a portion of the weight-bearing surface of the tibia 
may be included in the detached fragment. Displacements of frag- 
ments and of the astragalus are not nearly so frequent as in the eversion 
fracture. The foot is often held in a varus position. 

Symptoms. — The majority of these fractures show little displace- 
ment of the foot. "When it is present it is always inward and there is 
also moderate inversion. Lateral mobility may be detected, as in the 
eversion fracture; it is, however, not so pronounced and is always in- 
ward while in Pott's or eversion fracture it is outward. Posterior 
dislocation of the foot is extremely rare. There is localized pain and 
tenderness over the lower internal end of the tibia above the malleolus, 
and a small movable fragment of bone may be palpated and crepitus 



592 



TREATISE ON FRACTURES 



\ 



/ 



X 




FRACTURES OF THE TIBIA. AND FIBULA 



593 



is elicited. Over the external malleolus a loose fragment may also be 
discovered, but it is smaller than that seen in eversion fractures, and 
crepitus may be demonstrated by making lateral motion with the foot. 
There is generalized swelling about the joint and effusion within the 
joint. 

Prognosis. — These fractures usually should be followed with good 
functional results. There is not the same degree of injury to joint 
capsules and dislocation of fragments as there is in eversion fractures. 
Union occurs about the same time, and deformity is not so apt to be 
extreme. Efficient treatment is more likely to be obtained by the 

1 




Fig. 804. — Atypical inverted Pott's fracture. Note the high and trans 



of fracture of the 



patient because the damage to soft parts and the tendency to displace- 
ment are less formidable. 

Treatment. — In the majority of cases there is little displacement 
of fragments. Reduction may be accomplished without general anaes- 
thesia. Reduction is obtained by inward pressure above the ankle on 
the outer surface of the leg and outer pressure at the ankle and foot on 
the inner surface. The over-correction need not be used on account of 
the possibility of subsequent malposition. The foot should be placed 
at right angle to the leg. The foot and leg should be placed in pillow 
and side splint after reduction, and this form of dressing should be 
used for three to four days. After this time the leg and foot should be 
kept in a moulded gypsum case, which should be split into anterior and 
38 



594 



TREATISE ON FRACTURES 



posterior portions for observation of position. In fractures in which 
the internal malleolar fragment includes a part of the supporting tibial 
articular surface, it may be necessary to apply a gypsum case imme- 
diately after reduction on account of the tendency to recurrence of 
displacement of this fragment. 

Isolated Fractures of the Internal Malleolus ( Figs. 805 and 806) .— 
Isolated fractures of the internal malleolus are relatively infrequent. 
Many cases are probably considered -to be sprains. They are usually 
the result of a fall upon the foot when it is everted and abducted, or of 
a fall outward with the foot fixed. The injury is in essence of the 




/ 




;d S06. — Isolated fracture of the int 




same character as that seen in eversion fracture of the fibula, but it is 
not so severe a lesion. The osseous lesion is due to a forcible pull of 
the internal lateral ligament upon the malleolus, and the line of break 
usually is limited to the malleolus. At times only a small particle of 
bone is detached. There is very little displacement of the fragments 
and little if any deformity. In such cases sprain-fracture is a very 
appropriate term for the injury. 

Symptoms. — The usual symptoms are pain and tenderness limited 
to the region of the internal malleolus. There is generally a moderate 
degree of swelling in the region of the internal malleolus. Some lateral 
mobility of the foot may be possible in an outward direction, and with 
this movement crepitus may at times be developed. The lack of dis- 



FRACTURES OF THE TIBIA AND FIBULA 



595 



placement of the fragment is due to untorn portions of periosteum or 
ligament holding the fragments together. Patients are often able to 
walk. 

Prognosis. — With proper reduction and immobilization a good 
anatomical and functional result is the rule. 

Treatment. — Owing to the absence of displacement in the ma- 
jority of cases, the only treatment necessary is immobilization in a 
gypsum case until union is firm, which occurs in about five weeks. 
Cases of slight gravity may be treated with adhesive plaster straps 
carried around the instep and heel so as to give support, as in sprains 






Fig. 807. 



Fig. 808. 




Figs. 807 and SoS. — Isolated fracture of the external malleolus. 

of this region. If there is any displacement of the fragments of the 
malleolus, the same rules for reduction and immobilization hold good 
as given under eversion fracture. Care should be taken for some 
weeks to avoid slips during walking, which might throw strain on the 
union. If the lower fragment shows a marked tendency to displace- 
ment, it may, if comparatively large, be kept in position with a slender 
screw or nail. 

Isolated Fractures of the Lower End of the Fibula ( Figs. 807 and 
808). — Isolated fractures of the lower end of the fibula are frequent. 
They may be produced in two ways — by marked eversion of the foot 
as in the eversion already described, as a result of direct pressure of 
the astragalus upon the external malleolus, or by inversion of the foot, 
thus partaking of the nature of a tear- fracture. In the first variety 



596 TREATISE ON FRACTURES 

the line of fracture is usually about one and a half inches above the 
malleolus and may be oblique or spiral in direction ; in the second form 
the fracture involves the external malleolus itself, and the line is more 
transverse in direction and may consist of a tearing off of the tip or 
but a small piece of the cortex of the bone. 

Fractures by direct violence are extremely rare, and may involve 
any portion of the lower end of the bone. In only one of the above- 
mentioned types is there any tendency toward displacement. This 
occurs in the form due to eversion of the foot, where the line of frac- 
ture is well above the external malleolus. The astragalus may be 
slightly rotated outward, and the upper end of the lower fragment 
displaced inward toward the tibia. 

Symptoms. — The symptoms of fracture of the lower end of the 
fibula are localized pain, tenderness and swelling above the tip of the 
external malleolus. Crepitus may at times be discovered and abnormal 
mobility demonstrated by a finger placed on the extreme end of the 
lower fragment and rocking it inward and outward. When the frac- 
ture is limited to the very tip of the bony process, the only symptom 
present may be pain, tenderness and swelling limited to the malleolus. 
Some cases are very difficult to recognize from sprains. 

Prognosis. — The result, both anatomically and functionally, is usu- 
ally good. 

Treatment. — As there is rarely any displacement of the lower 
fragment, treatment consists in the use of a gypsum case applied from 
the toes to just below the knee, after the maximum swelling has dis- 
appeared. This dressing should be used for four weeks, and after 
the first few days removed daily for massage and passive motion. 
After the fourth week a supporting dressing of adhesive plaster is all 
that is necessary. Weight-bearing may be allowed at the end of the 
fifth week, but for several weeks care should be taken to avoid sudden 
strains on the external or fibulotarsal ligament or the broken process 
caused by mis-steps in walking. A laced shoe coming above the ankle 
in malleolar fractures should be worn for some time after cure. 

Fractures of the Anterior Articular Edge of the Tibia (Figs. 809 
and 810). — Fracture of the anterior articular edge of the tibia is an 
extremely rare injury. In a patient seen by one of the authors, the 
injury resulted from the- fall of a heavy beam upon the anterior region 
of the ankle-joint when the foot was fixed. 

Symptoms. — The symptoms of fracture are pain, swelling, and 
tenderness limited to the anterior region of the ankle-joint. Flexion 
and extension of the foot demonstrate crepitus, and with plantar 
flexion abnormal mobility of the fragment may be determined. 

Treatment. — Reduction is accomplished by direct pressure back- 
ward of the displaced fragment, the corrected position maintained by 



TREATISE ON FRACTURES 

immobilization of the foot and leg in a gypsum case, or an adhesive 
plaster cuff. A small pad or an indentation in the gypsum may 
in holding the fragment in place. Union occurs in from four to five 
weeks. Weight-bearing may be allowed at the end of five weeks 

Summary 
reduction" first always 

Upper End. — Fracture-box, not suspended, extending above knee: 
Cabot, lateral and posterior splints to control knee-joint in a similar 
manner: or a gypsum gauze encasement if not much swelling to be 
expected. In longitudinal fracture of head of tibia may. if needed, use 
drill pointed nail introduced through the skin to hold fragments in place. 

Shaft. — Suspended fracture-box: inclined-plane fracture-box: 
Cabot posterior and lateral splints, lateral and posterior contour splints : 
or perhaps Buck's traction (with counter-traction) from ankle, sole, or 
footboard of fracture-box. Gypsum encasement later. Division of 
tendon of Achilles occasionally. Operative treatment and fixation with 
Sherman plate in rebellious fractures 

Lower End. — Suspended fracture-box. or Cabot lateral and pos- 
terior splints. Gypsum gauze encasement later. Do not permit 
weight-bearing early. Operative treatment occasionally for recon- 
struction of mortise-joint at ankle. 

Deformed union should be treated, if bad. by osteotomy for restora- 
tion of weight-bearing in normal fine. 



CHAPTER XXIV 

FRACTURES OF THE TARSAL BOXES 

Anatomy (Figs. 811-813). — There are seven tarsal bones: as- 
tragalus, calcaneum, cuboid, scaphoid, and the external, middle and 
internal cuneiform. 

The astragalus articulates above with the tibia and fibula, below 
with the calcaneum, and in the front with the cuboid and scaphoid. 




Scaphoid 

, External 

cuneiform , ■ - 

Middle V- M ( \ 

cuneiform p:^;^ , j 

Internal <;*,.. V i 

1 T^'-J > 



Tuberosity of 
fifth metatarsal 



-ineiform 




Fig. 811. — Anterior view of bones of foot. (Davis.) 

It is an irregularly shaped bone, composed of a head, body, and neck. 
It has the trochlea for articulation with the tibia and fibula, the ex- 
ternal and internal processes, a posterior process, and the sulcus tali. 



600 



TREATISE ON FRACTURES 



The calcaneum is the largest of the tarsal bones and projects down- 
ward and backward to form the heel. It articulates with the astragalus 
by three articular facets, and with the cuboid. The various parts are 
the body, the tuberosity or posterior process, the internal and external 
processes, and the sustentaculum tali which projects toward the as- 
tragalus and bears the middle facet for articulation with the same. 

The cuboid is placed on the outer side of the foot between the 
calcaneum and the bases of the fourth and fifth metatarsal bones. It 
is an irregular cube in form. The scaphoid is situated at the inner 
side of the foot between the astragalus posteriorly and the three cunei- 
form bones anteriorly. Its long axis is placed transversely to the 
long axis of the foot. 

The three cuneiform bones are placed between the scaphoid pos- 

















s 


S^^^^^^^k_ 



Fig. 812. — Rontgenogram showing bones of normal foot, lateral view. 

teriorly and the bases of the first three metatarsal bones. They are 
wedge-shaped, the internal being the largest and the middle the smallest. 
Surface Markings. — Examination of the foot will show the fol- 
lowing bony landmarks: Posteriorly may be felt the tuberosity of the 
calcaneum. Proceeding forward from this point on the external sur- 
face palpation discloses the external tuberosity of the calcaneum, the 
external malleolus of the fibula, the tubercle on the peroneal ridge of 
the calcaneum about two and a half centimetres below the external 
malleolus, and the tubercle at the base of the fifth metatarsal bone. On 
the internal surface of the foot one can palpate the internal tuberosity 
of the calcaneum, the internal malleolus of the tibia, the sustentaculum 
tali two and a half centimetres below the internal malleolus, the tubercle 
of the scaphoid about two and a half centimetres anterior to the in- 



FRACTURES OF THE TARSAL BONES 601 

ternal malleolus, the internal cuneiform, and the prominence at the 
base of the first metatarsal bone. 

Statistics. — Plagemann's statistics based upon 1393 fractures ob- 
served at the Rostock clinic and diagnosed by radiographs show 114 
fractures (8.17 per cent.) of the bone of the foot, and of these $7 
fractures 2.65 per cent, were of the tarsal bones, divided as follows : 

Cases Per cent. 

(1) Isolated fractures of the calcaneum 17 1.22 

(2) Isolated fractures of the astragalus 5 0.359 

(3) Fractures of the astragalus and calcaneum 4 0.290 

(4) Isolated fractures of the scaphoid 7 0.509 

(5) Isolated fractures of the cuboid 1 0.07 

(6) Isolated fractures of the first cuneiform 3 0.21 

Fractures of the Astragalus. — Fracture of the astragalus is fre- 
quently associated with fracture of the calcaneum or of the fibula or 
with dislocation at the ankle-joint. 

Etiology. — Fractures of the astragalus are usually the result of 
great violence, which is occasionally direct; hence, they are often 
associated with severe injury to the soft parts, by which the fracture, 
may even be made open. The fractures often are due to a fall from a 
height, in which the astragalus is broken by being crushed between the 
tibia and the calcaneum. Forcible dorsal flexion and direct injuries, in 
which other fractures are produced, may also be the productive agency. 

Varieties. — Fractures of the astragalus may be divided as fol- 
lows : Fractures of the neck, fractures of the body, and fractures of 
the posterior (Stieda's) process. 

Fractures of the neck (Figs. 814-817) are usually transverse in 
direction and may be complete or incomplete. Usually there is very 
little displacement of fragments, unless the fracture is the result of 
great crushing violence, in which case there may be dislocation of one 
fragment and associated fracture of other bones or of the soft parts. 
The usual deformity in such cases is due to displacement of the body 
backward. 

Fractures of the body (Figs. 818-821) of the astragalus follow no 
definite lines. The injury is usually comminuted, although at times 
there may be three definite fragments, consisting of head and neck, 
body, and the posterior process. Marked displacement of fragments 
is rare. 

Fractures of the posterior process (Fig. 822) : In some instances 
the supposed fracture of the posterior process is not a fracture at all; 
the apparent fragment is an independent bone, the " os trigonum," an 
anomaly in man, which occurs, however, in the lower vertebrates as 
a normal component of the tarsus. In many instances, however, this 
process is an integral part of the human astragalus and is subject to 



602 



TREATISE ON FRACTURES 



fracture, either independently or in association with other fractures of 

the astragalus or of the tibia or fibula. 

Symptoms. — In the absence of displacement of fragments the 

symptoms of astragalus frac- 
ture consist of swelling about 
the ankle-joint, tenderness on 
pressure limited to the region 
of the astragalus, pain upon 
attempt at weight-bearing, and 
flexion of the foot. Crepitus 
may at times be detected by 
lateral motion. In some cases 
a positive diagnosis cannot be 
made clinically until swelling 
has ceased, and there is found 
evidence of callus, which may 
be palpable, and persistent 
limitation of motion at the 
ankle-joint. 

When there is actual dis- 
placement of a fragment, 
the piece generally may be 
felt in its abnormal position. 
There is loss of contour of 
the normal ankle, at times 
marked limitation of motion, 
and in compression fractures 
the level of the malleoli is 
lower than normal. The foot 
is usually everted and a 
moderate degree of valgus is 
present. In fractures of the 
posterior process there is pain, 
localized tenderness, and thick- 
ening behind the internal 
malleolus ; at times crepitus 
and some limitation of mo- 
tion. All suspected cases of 
fracture of the astragalus 
should be skiagraphed, and 
the variety of fracture and 

the degree of displacement of fragments thereby ascertained. 

Prognosis.— As the majority of fractures of the astragalus are 

unattended by any marked degree of deformity, union should occur in 




PlC. Ri.j. — RontKenoRram showing normal hones of 
foot, anteroposterior view. 



FRACTURES OF THE TARSAL BONES 



603 



a few weeks' time and the functional result should be excellent. When 
there is marked displacement of the fragments or comminution of the 
bone, the condition is serious as to satisfactory restoration of mobility 
of the ankle-joint. Staley collected 122 isolated fractures of the 
astragalus and 68 in which there were associated fractures of other 
bones. In 50 instances the displaced fragment or the entire astragalus 
was removed; amputation was performed in eight cases. In many of 
the severe fractures, mobility at the ankle-joint is permanently im- 
paired ; occasionally necrosis of the unreduced fragment takes place. 
There may be permanent ankylosis, and in open fracture death may 
result from septicaemia. Von Bergmann considers that the earning 
capacity is impaired, at least, 15 
to 20 per cent, or more, and on an 
average 30 per cent. 

Treatment. — In fractures un- 
attended by displacement of frag- 
ments, treatment consists in im- 
mobilization in a gypsum case ap- 
plied after maximum swelling has 
subsided. The foot, if possible, 
should be placed at right angles 
to the leg and in slight inversion. 
The case should extend from the 
toes to just below the knee; it 
should be split down on both sides 
for observation of the soft parts 
and correction of unsatisfactory 
position; and at the end of two 
weeks massage and passive motion 
should be instituted. Immobiliza- 
tion should be continued for 




i 



Fig. 814. — Fracture of neck of astragalus. 



from four to five weeks, and after this time should be replaced by 
an adhesive plaster supporting dressing. Weight-bearing should be 
instituted at the end of the seventh week. 

In closed fractures attended by displacement of fragments, a 
general anaesthetic should be given for reduction. By means of trac- 
tion applied to the foot and manipulation, it may be possible to obtain 
satisfactory reduction. If this is not possible, open operation should 
be performed, and the fragments reduced by leverage. When this 
cannot be effected, the displaced fragment should be removed. In 
open fracture attended by displacement of fragments, in which reduc- 
tion is impossible, the troublesome fragments should be excised. Satis- 
factory functional results attend removal of part or of the entire 
astragalus. After operation, the treatment will consist of immobiliza- 



604 



TREATISE ON FRACTURES 



<N> 



Fig. 815. — Compression fracture of neck of astragalus. 



\ 



of neck of astragalus. 



tion, followed by massage and passive motion. Cases may occur, per- 
haps, in which a fragment showing a tendency to slip out of place after 
reduction could he nailed in position by a drill or nail thrust through the 
skin. It is left in that position under an aseptic dressing for two or 
three weeks. 



FRACTURES OF THE TARSAL BONES 



605 



Results. — Stealy reviews 122 isolated fractures of the astragalus 
from the literature ; 8 were direct fractures. In 18 cases the head was 
extirpated and in 31 cases the body was dislocated and extirpated. In 
8 cases the entire astragalus was removed. Either malleolus was 
fractured in 1 1 cases and in 2 cases both malleoli were fractured. The 
os calcis was fractured in 15 cases and in two cases the os calcis was 
entirely removed. Twenty- four cases succumbed to septicaemia. 
Eight of these were classified in the isolated cases due to pressure 
necrosis. The foot was amputated _________«_„ ra ^ 

in 8 cases, and in 1 case both feet 
were amputated. 

Fractures of the Calcaneum. — 
Fractures of the calcaneum are the 
most frequent of the tarsal frac- 
tures. Formerly fractures of this 
bone were considered to be rare 
injuries, but the present frequent 
use of the Rontgen ray in examin- 
ing injuries of the lower leg and 
foot has demonstrated their com- 
parative frequency. 

Etiology. — Fractures of the cal- 
caneum result from falls from a 
height upon the foot in which the 
weight of the body is transmitted 
through the calcaneum, from falls 
upon the foot plus muscular action 
of the calf muscles, from sudden 
contraction alone of the calf mus- 
cles, from direct violence, and from 
forcible inversion of the foot. 

Varieties (Figs. 823-832).- — The following types of fracture are 
observed : avulsion, transverse, compression, and of the sustentaculum. 
Avulsion fractures are due to sudden contraction of the gastrocnemius 
and soleus muscle with the foot in a flexed position. The line of frac- 
ture is not on the walking surface of the bone, the detached fragment 
consisting either of a considerable portion of the upper and posterior 
part of the posterior process or of a small cortical piece at the point of 
insertion of the tendon of Achilles. The displacement of the fragment 
ma}- be very slight, which is usually the case when the fragment is 
large ; or it may be extreme in those cases in which only a small cortical 
fragment is torn loose. The fracture line may rarely involve a portion, 
or the entire epiphysis, of the posterior process. Transverse fractures 
are due to direct violence. The line involves the walking surface of 




606 



TREATI-K I -X FRACTURES 



the bone, and usually runs from a point about midway on the upper 
surface downward and backward, so that a large posterior fragment is 
produced. This is rotated about a transverse axis, the upper end of the 
posterior fragment being somewhat displaced upward while the lower 
anterior portion of the calcaneum is displaced somewhat downward. 
Marked displacement is limited by the attachment of the plantar fascia. 
Compression fracture occurs. These fractures may be recognized 
radiographically only by changes in the density of the shadow, in the 
shape of the os calcis or its typical lamellar structure, and the evidence 
of unusual angularity of the bone. In the more severe types of this 



• . . - 

fracture, distinct compre minution and displace! 

ments may be readily recognized. The t 

the anterior half of the bone: in some cases the fracture line involves 
the entire calcaneum. Irregularit fragi 

characteristic and vertical compression usual. These fractures are 
usually the result of falls upon the foot and only rarely of direct 
violence. The astragal wedge and is forced through 

the calcaneum. The degree «n and of comminution 

direct rati.* to the - the fall and the weight of the patient. 

ited fractures of the malleoli are occasionally seen. The - 
the lesion is dependent, to a great degree, upon the position of the 
tt the time which thc 



FRACTURES OF THE TARSAL BONES 



607 



astragalus rests (sustentaculum tali) are rare and usually associated 
with fracture of other portions of the calcaneum. Isolated fractures 
of the sustentaculum are extremely rare. The fracture results from a 




r 



Fig. 819. — Compression fiacture of body of astragali: 



\ 



/ 



Fig. 820. — Compression fractures of body of astragalus and of calcai 
scaphoid joint. 



ith dislocation at astragak 



fall upon the foot when it is in position of marked inversion. The 
resulting deformity is a pes valgus. 

Plagemann's statistics of 17 isolated fractures of the calcaneum 
shows 10 compression fractures of the entire body of the calcaneum 



G08 



TREATISE ON FRACTURES 



with a partial or complete tearing off of the sustentaculum tali ; 4 frac- 
tures of the posterior process ; 2 fractures of the anterior portion and 



/ 



Fig. 821. — Compression fracture of body of astragali: 



\ 



Fig. 822. — Fracture of the posterior process of the astragalus. 

body, and 1 fracture of the posterior process and body of the cal- 

im. In 4 of these 17 cases there was an associated fracture of 

the astragalus, consisting twice of a fracture of the neck, once a frac- 



FRACTURES OF THE TARSAL BONES 609 

Fig. 823. 




Figs. 823 and 824. — Types of tear-fracture of the posterior process of the calcaneum. 

ture of the posterior process and once a fracture of the posterior proc- 
ess and neck of the astragalus. In these cases the fracture line of the 
calcaneum was a continuation of the fracture line of the astragalus. 
Symptoms. — The frequency with which fracture of the calcaneum 
39 



610 



TREATISE ON FRACTURES 

Fir,. 825. 




Fig. 825. — Type of tear-fracture of the posterior process of the calcaneun 
Fig. 826. 



Fig. 826.-- Type of fractures of posterior process of calcaneum. 



FRACTURES OF THE TARSAL BONES 

Fig. 827. 



y 




Figs. 827 and 828. — Types of fracture of posterior process of calcaneum. 

is overlooked is due in a great measure to the fact that unless there is 
marked displacement of fragment the symptoms are slight and unat- 
tended by absolute disability. Careful inspection and examination 



612 



TREATISE OX FRACTURES 

Fig. 829. Fig. 830. 




the calcaneum. 



should render the diagnosis positive in the majority of cases, and in the 
remaining this may be done by the use of the rdntgenogram. Tne 
characteristic symptoms are swelling in the region of the astragalus 
and about the ankle, thickening posterior to the midtarsal region. 
usually on the internal and external surface of the foot below the 



FRACTURES OF THE TARSAL BONES 



013 



malleoli, and marked limitation or at times entire absence of lateral 
motion of the foot (Fig. 833), although flexion and extension at the 
ankle-joint are free. Cotton lays great stress upon the thickening 
found, in nearly all fractures of the body of the calcaneum, on the 
external surface of the bone beneath the external malleolus, and con- 
siders it to be due to the detachment and forcing outward of a thin 
cortical fragment from spreading of the bone beneath it. At times 
there is upward displacement of the posterior fragment with corre- 




sponding flattening of the foot, so that a valgus position is present. 
Crepitus at times may be detected. In many cases the weight of the 
body can be borne upon the injured foot. In severe compression 
fractures, the malleoli may be nearer to the sole of the foot than is nor- 
mally present. There are in addition localized pain, tenderness on 
pressure, ecchymosis, and usually characteristic broadening below the 
malleoli, seen best from a posterior view (Fig. 834). In avulsion frac- 
ture the displaced fragment may generally be felt in its abnormal 
position. When practicable, radiographic examination should be made 



614 



TREATISE OX FRACTURES 




- 

■videniag of cl - 2ich of 



I i determine not only the variety of fracture but a)><< t": 
displacement of fragments and to - lesions of other 

Prognosis. — In fractures • with displacement of frag- 



FRACTURES OF THE TARSAL BONES 



615 



ments the prognosis is good as regards function. The same cannot be 
said of fractures in which there is comminution or displacement of 
fragments. In these cases non-operative methods of treatment are 
apt to be attended by poor functional results and marked decrease in 
earning efficiency. This is due to loss of the arch of the foot, to the 
projection of fragments into the sole of the foot, making walking pain- 
ful, to loss of lateral motion of the foot and to pain due to relaxation 
of ligaments. 

Treatment. — In fractures unattended by displacement of frag- 
ments, treatment consists in immobilization in a gypsum case applied 
from the toes to below the knee for a period of three to four weeks. 
This is to be associated with, or followed by, massage and passive 
motion; weight-bearing should be allowed at the end of six or eight 
weeks. In many cases, however, 
there is displacement of fragments. 
Four forms of displacement are 
amenable to treatment by reduc- 
tion. A general anaesthetic is 
usually required for reduction of 
fragments. 

If displacement cannot be cor- 
rected by traction and manipula- 
tion, operative measures should be 
adopted. In fractures attended by 
upward displacement of the pos- 
terior process, reduction may be 
accomplished by the introduction 

Of a Spindle through puncture fracture of" the posterior process of the calcan 
r . with upward displace 

holes just m front of the point 
of insertion of the tendon of Achilles as suggested by Cotton (Fig. 
835). Traction is made on this spindle and the fracture reduced. 
If reduction cannot be maintained, tenotomy of the tendon of Achilles, 
either alone or combined with nailing of the fragments in their 
normal position, should be done. After reduction, immobilization 
with the foot in slight plantar flexion of the ankle in a gypsum case 
should be used. Fractures attended by lateral broadening below 
the malleoli should have this displacement corrected by Cotton's 
operative method (Fig. 836). This consists in placing the inner sur- 
face of the foot upon a sand-bag, and protecting the outer surface of 
the calcaneum by a felt pad; after which impaction of fragments is 
obtained and reduction of displaced fragments accomplished by re- 
peated blows with a wooden mallet. A gypsum case is used after reduc- 
tion. In fracture attended by displacement of sharp fragments from the 
weight-bearing surface of the calcaneum into the plantar muscles. 




Pig. 835. — Cotton's method of reduction of a 
lire of the posterior process of th 
upward displacement of the fragn 



616 TREATISE ON FRACTURES 

open operation should be the plan of procedure, with excision of these 
fragments. 

Fractures attended by upward displacement of a portion of the 
posterior process due to pull of the tendon of Achilles may be subject 
to open operation. Thi« consists in exposure of the fragments through 
a curved posterior incision, approximation of the fragments, and suture 




Fig. 836.— Cotton's 



with kangaroo tendon. Tenotomy of the tendon of Achilles may also 
be necessary (Figs. 837 839). 

Fractures of the Tarsal Scaphoid. — Fractures of the tarsal scaph- 
oid ( Figs. 840 845) arc rather rare injuries and usually are the result 
of direct violence, in which there may also be associated fractures of 
other bones of the foot. These fractures may be comminuted and 
open, or may partake of the character of avulsion fractures. Frac- 
ture-, by indirect force are due to falls upon the foot in which the foot 
is in a position of plantar flexion and the weight is received upon the 




-fiG. 837. — Fracture of the body of the calcaneum with upward displacement of the fragment. 




018 



TREATISE OX FRACTURES 



toes. As a result the scaphoid is cushioned between the astragalus and 
the internal cuneiform. In a few instances the fracture is the result of 
a twist of the foot or a mis-step. The insertion of the posterior tibial 
muscle into the bone accounts for some of the tear-fractures of the 
tubercle of the scaphoid. The usual site of fracture is the tubercle, 
although in fractures clue to direct violence any portion of the bone 

may be the seat of injury. Usu- 
ally there is a moderate degree 
of displacement of the frag- 
ment of the tubercle; in some 
instances the dorsal fragments 
may be pushed upward under 
the tendons on the dorsal sur- 
face of the foot. 

Symptoms. — The symptoms 
of fracture of the tarsal scaph- 
oid depend in some degree 
upon the site of fracture. There 
is always marked pain and 
tenderness on pressure over the 
inner and dorsal surface of the 
instep, that is, in the region of 
the scaphoid. Pain is increased 
by weight-bearing. Some local 
swelling and possibly ecchymo- 
sis are present. The foot pre- 
sents a valgus position, and ab- 
duction is usually marked. Pain 
is usually referred up the leg 
along the course of the posterior 
tibial muscle, and on account of 
the attachment of this muscle 
to the tubercle of the scaphoid 
Fig. 8j9.— Method of approximation of fragments the latter is pulled inward ; the 

in fracture of posterior portion of body of calcaneum J • • . 

by open operation. The fragments are secured by two antagonistic pSrOlietlS mUSCleS 

interrupted sutures of kangaroo tendon passed through H ,. » , . , •, 

in the bone and the torn periosteum is united pull the foot into .1 ValgUS pOSl- 

by interrupted chromic catgut sutures and the skin by . , ,. - . . ,. 

interrupted linen thread. Immobilization is maintained tlOll, and af ter a t lllie HgldltV O t 

by a gypsum case. ii.fi.-ii 1 

the foot in the valgus position 
results. Forced abduction of the foot increases pain at the site of frac- 
ture, as this motion separates the fragments of the scaphoid. Displace- 
ment of fragments can always be recognized by palpation. When 
severe compression or dislocation of fragments is present, the inner 
measurement of the foot is shortened. Suspected cases should be 
radiographed. Occasionally there is a sesamoid bone in the tendon 




FRACTURES OF THE TARSAL BONES 



619 




L 



620 



TREATISE OX FRACTURES 






FRACTURES OF THE TARSAL BONES 621 

of the posterior tibial muscle ; its presence should not mislead one into 
assuming the presence of fracture. Examination of many radio- 
graphs leads to the belief that the tubercle of the scaphoid is not 
developed from an individual centre of ossification. 

Prognosis. — In the majority of unrecognized and unreduced cases 
of fracture of the tarsal scaphoid, traumatic flat-foot is the result. 
Severe compression fracture of this bone is followed by markedly poor 
function and a painful, weak foot. 

Treatment. — When there is no marked displacement of frag- 
ments, treatment consists in immobilization of the foot and leg in a 
gypsum splint for three to four weeks. The foot splint should be 
applied with the foot in moderate inversion and adduction. Slight 
massage should be performed from the beginning of treatment or from 
the end of the second week, and weight-bearing allowed at the end of 
the sixth week. Cases complicated by marked displacement of frag- 
ments demand open operation, reduction of fragments, and later im- 
mobilization. Most of the patients should use a felt pad for support- 
ing the arch of the foot for several months. Metal arch supports are 
not recommended. 



CHAPTER XXV 

FRACTURES OF THE METATARSAL BONES 

Anatomy. — The five metatarsal bones consist of a base, a shaft, and 
a head. The first metatarsal is the largest and the second the longest. 
The bases of the first and fifth metatarsal bones present a broad 
projection called the tuberosity. 

Surface Markings. — The first and fifth metatarsal bones can be 
readily and the other three fairly well palpated throughout their entire 
length. The tuberosity of the fifth metatarsal is prominent on the 
outer surface of the foot. 

Statistics. — Plagemann's statistics show 49 fractures of the meta- 
tarsals in 1393 cases, distributed as follows: first metatarsal, 9 times; 
second metatarsal, 12 times; third metatarsal, 3 times; fourth meta- 
tarsal, 4 times; fifth metatarsal, 9 times; first and second metatarsals, 
4 times ; first, second, third, fourth and fifth metatarsals, 2 times ; first, 
second and fourth metatarsals, once ; second and third metatarsals, 3 
times; fourth and fifth metatarsals, once; and first, second and third 
metatarsals, once. 

Etiology. — Fractures of the metatarsal bones (Figs. 846-852) are 
usually the result of direct violence, as from falling objects, and 
crushing injuries, and occasionally from indirect violence, as in jump- 
ing and prolonged marching. Fractures of the fifth metatarsal, while 
occasionally produced by direct violence, are usually due to a sudden 
throwing of the weight of the body upon the foot, when the latter is in 
a position of inversion, as in dancing, jumping from a moderate height, 
or in a mis-step. 

Symptoms. — Fractures from direct violence are generally accom- 
panied by considerable bruising of the overlying soft parts, so that 
there is marked swelling, localized pain, tenderness on pressure, and 
ecchymosis. Crepitus can frequently be detected and the fragments 
may be moved in any direction. Some of these fractures can be de- 
termined positively only by the radiogram, and many of them are 
overlooked. After swelling of the soft parts has disappeared, displace- 
ment of fragments can be recognized. The lines of fracture may be 
oblique, transverse, or comminuted, and rarely are longitudinal. Mul- 
tiple fractures are frequent. Longitudinal fractures are seen only in 
the first metatarsal. 
f>22 



FRACTURES OF THE METATARSAL BONES 



623 



Fig. 846. 



Fig. 847. 






Of particular interest are fractures of the fifth metatarsal. Isolated 
fracture of this bone when not the result of direct violence is due to 
inversion of the foot under the weight of the body. It is produced by 



I 




\ ~* 



— i 




i 





FRACTURES OF THE METATARSAL BOXES 



625 



direct pressure upon the outer part of the foot. As the foot is turned 
inward and the weight of the body brought upon the outer surface of 
the foot, strain is brought to bear upon the base of the bone, which is 
held firmly to the fourth metatarsal and cuboid bones by strong liga- 
ments. As a result of this strain, fracture usually occurs at the base. 
The following varieties of fracture may be recognized : fracture 
through the tip of the tuberosity (Figs. 853-855) ; fracture through 
the base of the tuberosity (Figs. 856 and 857) ; transverse fracture 
through the proximal end of the shaft (Figs. 858 and 859) ; and 
fracture through the shaft of the bone (Figs. 860-864). 

The symptoms of inversion fracture of the fifth metatarsal are 
localized pain, tenderness on pressure, partial disability, localized swell- 




Figs. 853, 854, and 855- — Types of fractures of the tip of the tuberosity of the fifth metatarsal. 



ing, and pain referred to the seat of fracture upon lateral squeezing of 
the foot just above the heads of the metatarsals. Crepitus may at 
times be determined, particularly when the line of fracture occupies 
the shaft of the bone (Fig. 865). Radiograms will make a positive 
diagnosis, although in many cases it may be made from the character 
of the injury, and the localized tenderness, pain, swelling and late 
ecchymosis. 

Prognosis. — Fractures by direct violence are usually attended by 
marked displacement of fragments. Unless such displacement is re- 
duced, union takes place with deformity, and there is the presence of a 
marked projection, either dorsally, which gives considerable discom- 
fort on account of shoe pressure, or the fragment may be displaced 
into the plantar region of the foot, with secondary nerve pressure and 
40 



626 



TREATISE < m FRACTURES 






S 




Figs. 856 AND 857. — Types of fracture of the base of the tuberosity of the fifth metatarsal. 




Fu;s. 858 AND 850. — Types of fracture through the proximal end of the shaft of the fifth metatarsal. 

consequent disability, [n fracture of the fifth metatarsal by inversion, 
union usually occurs with very little deformity and the functional 
results are good. 

Treatment. — Reduction of fragments should be accomplished by 
traction and manipulation. Anteroposterior displacements should 



FRACTURES OF THE METATARSAL BOXES 627 

Fig. 860. Fig. 86 r. 




Figs. 8Go, 86i, 862, and 863. — Types of fracture of the sha 
fractures when caused by inversion of the foot are spiral in char 
they are usually transverse or oblique in character. 

always be corrected, even if open operation is necessary. Immobiliza- 
tion after reduction should be by means of a well-moulded plantar 
gypsum splint or a carefully padded wooden splint. If incision is 
necessary for reduction, fixation should be accomplished by direct 
suture with chromic catgut followed by the use of an external gypsum 



628 



TREATISE OX FRACTURES 



splint. Immobilization with frequent light massage should be con- 
tinued for from four to five weeks. Weight-bearing may be instituted 
at the end of six or seven weeks. 

Old cases, in which there is union with deformity and loss of 




of the shafts of the 



function due to pressure, call for operation and excision of projecting 
spurs of bone. 

In fractures of the fifth metatarsal by inversion, there is little 
displacement of fragments, and treatment consists in immobilization 
by a gypsum encasement or splint for four weeks. 



CHAPTER XXVI 

FRACTURES OF THE PHALANGES 

Fractures of the phalanges (Figs. 866-870) are the result of 
direct violence. Exceptions to this statement are those fractures 
which occasionally result from stubbing the toe ; in these the force is 
received on the point of the distal phalanx. These fractures may be 
subcutaneous, or open, comminuted and complicated. The line of frac- 
ture may be transverse, oblique, comminuted, T or Y, or longitudinal. 
Of particular interest have been two cases observed by one of the 
authors. One consisted of a fracture of an exostosis of the distal 




Fig. 866. — Transverse fracture of the proximal phalanx the great toe. 
Fig. 867. — Oblique fracture of the proximal phalanx of second toe. 

phalanx of the great toe, and the other a longitudinal fracture of the 
distal phalanx of the great toe involving epiphysis and diaphysis, the re- 
sult oi direct violence. Open comminuted fractures are frequent from 
crushing of the toe by machinery or impact of heavy objects on the foot. 

Symptoms of phalangeal fractures are localized pain, swelling, 
ecchymosis, tenderness on pressure, crepitus, and abnormal mobility. 

Treatment. — Displacement of fragments is rarely great. Reduc- 
tion is readily accomplished, and immobilization made either by strap- 
ping the toe to the adjoining one, or by using a plantar splint. Union 
occurs in three to four weeks and functional results are good. 

629 



630 



TREATISE ( >N FRACTURES 




CHAPTER XXVII 

FRACTURES OF THE SMALL SESAMOID BONES 
Anatomy. — Sesamoid bones are small osseous structures developed 
in tendons, are situated at that part where tendons play over joints, 
and are subject to considerable pressure. They make their appearance 
as osseous structures about the twelfth year. These small structures 
may be ossified or they may be represented by fibrocartilage. One 
surface of the bone is usually covered with cartilage and enters into 
the formation of the joint, or is separated from the latter by a bursa. 
Manv of the sesamoid bones are constant and are ossified ; and as such 




Fig. 8?r. — Constant sesamoid bones of the thumb. 
Fig. 872. — Shows only one constant sesamoid bone at the metacarpophalangeal joint of the 
thumb, one accessory sesamoid at the head of the second metacarpal, one at the head of the third 
metacarpal, and two at the head of the fifth metacarpal. 

show by radiography, when formed of fibrocartilage no shadow is 
found. The largest sesamoid is the patella. 

The constant sesamoid bones (Figs. 871-874) of the hand are 
those occurring at the metacarpophalangeal joint of the thumb. They 
are two in number, are joined together by fibrous tissue and form the 
floor of the groove of the flexor longus pollicis tendon. 

The constant sesamoid bones of the foot (Fig. 875) are two in 
number and are situated on the plantar surface of the head of the first 
metatarsal bone near the metatarsophalangeal articulation. They are 
united by fibrous tissue and form the floor of the groove for the tendon 
of the flexor brevis ballevia. 

631 



032 



TREATISE ON FRACTURES 

Fig. 873. FlG - 8 ™- 




Figs. 873 and 8; (.—Shows two accessory carpal sesamoid bones in tendon sheaths of flexor tendon 
to fifth finger. 




Fics. 876.— Type of 



—Constant sesamoid bones at head of the first metatarsal bone, 
trigonum. This is often mistaken for the so-called Shepherd's fract 
posterior process of the astragalus. 



Of the inconstant or accessory sesamoid bones of the hand, may 
be mentioned the following: There is sometimes found a third or 
accessory sesamoid at the metacarpophalangeal joint of the thumb, 
also one at the interphalangeal joint of the thumb; one between the 
flexor tendon and the head of the second metacarpal ; one between the 



FRACTURES OF THE SMALL SESAMOID BONES 



633 




Fig. 877.— Type of os trigonum. This is often 
mistaken for the so-called Shepherd's fracture of 
the posterior process of the astragalus. 



flexor tendon and the head of the fourth metacarpal, and one between 
the flexor tendon and the head of the fifth metacarpal. Two accessory 
sesamoids have been noted at the 
head of the fifth metacarpal and 
accessory carpal sesamoids in 
flexor tendons at the wrist. 

Fawcett's statistics, based upon 
rontgenologic examination of 38 
pairs of hands, show the sesa- 
moids in the index-finger in 55.2 
per cent. ; in the fifth finger in 71 
per cent, and in the interphalan- 
geal joints of the thumb in 69.3 
per cent. 

Geist examined the feet of 100 
persons who never had an injury 
or foot complaint, and of these 
there were 30 presenting accessory 
sesamoid bones, which he divides 
as follows: Important group: os 
trigonum, os tibiale externum, os 
peroneale, and os Vesalii. Unim- 
portant group : secondary os calcis, 
os intermetatarsale, and os inter- 
cunei forme. 

The os trigonum (Figs. 876 
and 877) is situated at the back 
part of the astragalus. It may be 
small or large, double or single. 
The so-called Shepherd's fracture 
as a rule is nothing more than this 
os trigonum. This bone was found 
7 times in this series, was always 
unilateral, while in 3 of the 7 cases 
a larger posterior process was 
noted in the other foot. The os 
tibiale externum (Fig. 878) was 
formerly considered as accessory 
bone in the tendon sheath of the 
tibialis and situated behind and 
slightly below the tubercle of 
the scaphoid. It is often unilat- 
eral and is often mistaken for a 

, - , , , r , Fig. 879. — Double os peroneale, situated in the ten- 

fractUre O'f the tubercle Of the don of the peroneus longus muscle. 




634 TREATISE ON FRACTURES 

scaphoid. Fourteen cases were seen in the series of ioo; single in 
9, double in 5. On one side there may be an absolutely loose tibiale 
externum, and on the other side it may be represented by a large tubercle 
of the scaphoid. The os peroneale (Fig. 879) is apparently a true 
sesamoid bone, being situated in the tendon of the peroneus longus 
muscle. It was found present in 7 cases, being single in 3 and double 
in 4 cases. In two of these cases it was bipartite. 

The os Yesalii is situated at the base of the fifth metatarsal bone. 
It is very rare and was found once in 100 cases. The secondary os 
calcis occurs extremely rarely. In this series it was found twice. 




Fig. 880. — Accessory sesamoid in the tendon of the gastrocnemius muscle. 

Fig. 881. — Shows the two constant sesamoids at the head of the first metatarsal, and accessory sesamoids 

at the heads of the second, third, fourth and fifth metatarsals. 

"When present it may simulate a broken off part of the sustentaculum 
tali. The intercuneiforme is a small wedge-shaped bone situated be- 
tween the internal and middle cuneiform bones. It was found in two 
cases. The intermetatarsaleum is considered by Dwight to occur in 
10 per cent, of all cases. It is difficult to recognize by radiograph and 
is found between the bases of the first and second metatarsal bones. 

Pfitzner found sesamoid bones on the fibular side of the fifth toe in 
6.2 per cent. ; on the tibial side of the fifth toe in 5.5 per cent, and on 
the tibial side of the second toe in 1.8 per cent. 

Occasionally there is observed in addition to the two constant 
sesamoids of the great toe a third or accessory sesamoid. Frequently 
there is seen an apparent fracture, particularly of the tibial sesamoid 
of the great toe, which is considered by many authorities to be an 
anomalous division of the sesamoid into two parts. This may be 



FRACTURES OF THE SMALL SESAMOID BONES 



G35 



definitely ascertained at times by having radiographs of both feet taken 
not only in anteroposterior planes but also laterally. An unusual situa- 
tion of accessory sesamoid is in the tendon of the gastrocnemius muscle 




Fig. 883.— Fracture of the tibial 



d of the great toe. Injured while playing basket-ball. 



(Fig. 880). Pancoast considers that it is present in about 12.5 per 
cent, of cases and usually found in the outer head of the muscle. It 
has been mistaken for a loose body in the popliteal bursa or in the 



o36 



TREATISE ON FRACTURES 



knee-joint. Accessory sesamoids are also found at the heads of the 
metatarsal bone. 




TlG. 8S4. — Fracture of fibular sesamoid, accompanying comminuted fracture of the head of the first 

metatarsal. Injured by a falling weight striking foot. 

FlG. SS3. — Fracture of the tibial sesamoid. Form of injury not ascertained. 




Etiology. — Fractures of the sesamoids other than the patella have 
been observed involving those of the thumb and the great toes. Frac- 
tures of the sesamoids of the great toe (Figs. 882-887) result from 



FRACTURES OF THE SMALL SESAMOID BONES 637 



direct violence, such as jumping on the toes, run-over accidents, sudden 
falls upon the feet, and the impact of falling objects on the foot. Frac- 
tures of the sesamoids of the thumb (Figs. 888 and 889) may be the 
result of catching rapidly moving objects, such as a baseball, or they 
may accompany dislocation at the metacarpophalangeal and inter- 
phalangeal joints. Stumme (quoted by Mutter) showed on the cadaver 
that fracture of the tibial sesamoid bone may be produced by forcible 
dorsiflexion with abduction. 

Symptoms. — The symptoms of fracture of the sesamoid bones of 
the great toe are persistent pain and tenderness on walking on the 
plantar surface of the foot over the region of the sesamoid, usually 
this tibial sesamoid bone. In addition there is generally history of an 
injury either from a direct fall upon the foot or by a falling weight 

Fig. 888. Fig. 889. 




Fig. 888. — Old fracture of interphalangeal sesamoid in a baseball player. 

Fig. 889. — Fracture of the sesamoid of the thumb. Patient fell upon extended thumb. 

(Courtesy of Dr. P. G. Skillern, Jr.) 

striking the foot over the sesamoid region of the great toe. Similar 
symptoms are caused by fracture of manual sesamoids. An absolute 
diagnosis may be made only with the radiogram, which will show the 
dentated margin of fracture. Anteroposterior and lateral views of 
both feet should be made for a comparison so as to avoid diagnosing 
an anomalous division of the sesamoid as a fracture. Occasional 
ossification of portions of tendons near joints may be mistaken for 
sesamoids, and fractures of osteophytes may be erroneously diagnos- 
ticated as broken sesamoids, and vice versa. 

Treatment. — This consists in immobilization of the foot or hand 
upon a moulded gypsum plantar or palmar splint for three or four 
weeks. If pain and soreness on use of the hand or in walking persist, 
excision of the fragment should be performed. 



CHAPTER XXVIII 
BIRTH FRACTURES 

Birth fractures are observed rather infrequently. E. D. Trues- 
dell. in a study of about 9000 eases delivered at the New York Lying-in 
Hospital, has found 14 fractures of the humerus. 10 fractures of the 
clavicle, and 2 fractures of the femur. He later reports a separation of 
the lower femoral epiphysis, and G. YV. Kosmak. from the same insti- 
tution, reports four cases of depressed fractures of the skull. 

Depressed Skull Fractures — Etiology. — Depressed fractures of 
the skull in the new-born occur in difficult labor and are the result of 
pressure from forceps in instrumental delivery or of some projecting 
deformity in the pelvis. 

There are frequently areas of subdural hemorrhage and of oedema 
after difficult labor with or without forceps deliver}-, but in time these 
areas disappear by absorption without any permanent injur}- to the 
brain. In depressed fracture of the cranial bones this does not readily 
occur. Although at times the brain may accommodate itself to small 
areas of permanent depression, subsequently these deformities of the 
surface of the skull may possibly exert a deleterious effect on the 
functions of the brain. The depressed areas sometimes disappear of 
themselves : as a rule they persist and may leave the patient the subject 
of nervous disturbances, epilepsy, idiocy, and other mental changes. 

Symptoms. — In some of the cases there will be entire absence of 
symptoms, excepting the presence of the depressed area of bone. If 
the depression is sufficiently marked to cause compression, or over 
important cerebral centres, the respirations may be slow and labored, 
the heart action slow and weak, and irritative or paretic symptoms 
arise. The child may not cry. and the pupils may be unequal and fail 
to react to light. Partial asphyxiation may be present, and there may 
be at first muscular twitchings or paralysis, depending upon the degree 
and extent of the depressed area or its location over motor centres. 

In all cases of prolonged labor, contracted pelvis, or instrumental 
deliver}-, the head of the child should te carefully examined for areas 
of depressed fracture. The presence of a caput succedaneum may 
conceal an area of compression, so that, when it is present, repeated 
examination should lie made. When areas of depression are found to 
. they should be elevated promptly by operation, for it is unwise 
to expect intracranial pressure to force the depressed area of the skull 
out to its normal contour. 

Treatment. — When an area of depre-^i->n i< found, correction 
should l>e made as soon as recognized. Kosmak has devised an instru- 
■ 



BIRTH FRACTURES 639 

ment for the correction of depressed fractures of the skull, which con- 
sists of a hook with a handle. The hook is placed at a right angle to 
the shaft of the instrument and is mounted on a handle for convenience 
in using. The hair over the depressed area is clipped with scissors, the 
area painted with tincture of iodine, and the point of the instrument 
forced by firm and constant pressure into the centre of the depressed 
fracture. When the point has penetrated the inner table of the skull, 
the handle of the instrument is turned at right angle to the surface and 
steady traction made outward until the depressed area is elevated. A 
sterile dressing and bandage complete the operation. A small trephine 
may be used to* gain admission for an elevator which can then be used 
to prize up the depressed portion of the calcaneum. 

Fracture of the Humerus — Etiology. — Truesdell's observations 
upon fractures of the humerus in the new-born show, of the 14 cases 
observed, that 10 occurred during version and breech extraction, 3 
during simple breech extraction, and 1 in spontaneous vertex delivery 
in which difficulty was met in extracting the anterior arm on account 
of a narrowed pelvic outlet. 

The line of fracture in 13 of these cases was transverse in direction, 
near the centre of the shaft, or just below the insertion of the deltoid 
muscle ; in the other case the fracture was produced by the application 
of a fillet to the prolapsed arm in a shoulder presentation followed by 
traction upon the limb while version was being performed. The 
fracture was produced by torsion of the arm across the child's back. 
The line of fracture in this case was oblique. 

Deformity. — In the majority of cases this was primarily absent 
but later occurred, either by the child's muscular efforts or by the 
manipulations of the nurse in handling the child. The deformity then 
assumed one of external angulation. In a few cases there was lateral 
deviation of fragments. Over-riding of fragments was extremely 
rare (Fig. 890). 

Every fracture of the humerus observed by Truesdell was accom- 
panied by wrist-drop. This is considered by the author to be due 
either to posterior pressure upon the nerve occurring before the pro- 
duction of the fracture, or to implication of the nerve between the 
fragments. Of two cases which died the author was able to examine 
the seat of fracture, and in neither of these two was there any evi- 
dence of violence to the brachial plexus or the musculospiral nerve. 
In one case the author noted the occurrence of an Erb birth palsy in 
the injured arm. 

Symptoms. — The presence of fracture of the humerus may be 
readily recognized by the evident disability to use the arm, wrist-drop, 
deformity, localized pain at the seat of fracture, and crepitus. 

Treatment — Prophylaxis. — While Kosmak considers that frac- 



«>40 



TREATISE ON FRACTURES 



ture of one of the long bones is never a very serious lesion in com- 
parison with depressed skull fractures, he thinks that it may often be 
possible to avoid the complication by correct diagnosis of the exact 
position of the arms of the child before the body is born. A correction 
of the brachial malposition is then possible before extraction of the 
child. He urges that so soon as the umbilicus is born in a breech 
extraction with or without previous version, the fingers of the examin- 
ing hand should be introduced over the posterior vaginal commissure 





Fig. 890. — Fractures of right humerus and both clavicles. The fracture of the humerus is situated 
i, the line of fracture is oblique. The outward rotation of the lower frag- 
ment may be prevented by fixation of the forearm to the front of the chest wall. (Courtesy of Edward 
U. Truesdell. M.D., New York Lying-in-Hospital.) 

and the position of the arms in relation to the head determined. If 
the arms are extended, or one of them is caught behind the neck in the 
form of a nuchal hitch, it is much easier to sweep them over the face 
into a position of flexion before final delivery than to attempt this 
manoeuvre after the greater portion of the trunk has l^een born. At 
thi> time the head has not been wedged into the pelvic entrance, and 
1 he arm^. if extended, can usually be released without much difficulty. 
It has been found practical never to rely on any flexion of the arms 
being maintained through pressure exerted on the fetal head through 



BIRTH FRACTURES 641 

the lower abdominal segment. Nearly always the arms will become 
extended during version, and this fact might as well be recognized 
before the posture of the arms becomes a source of danger to either 
mother or child. 

In the treatment of these fractures the difficulty of maintaining 
immobilization of fragments is apparent. The simplest form of treat- 
ment consists in surrounding the arm with coaptation splints, and fixing 




Fig. 891. — Fracture of shaft of femur, at end of te 
angulation, and large and firm callus. (Courtesy of E 
in-Hospital.) 

the arm and forearm to the chest by means of a bandage applied to the 
shoulder and arm as suggested by Velpeau. Union occurs in about 
three weeks. Truesdell has devised a splint made of sheet aluminum, 
cut and folded in such a manner that the external angular deformity 
is corrected. The splint at the same time fixes the arm to the body, 
flexes the elbow, and entirely immobilizes the arm. 

Truesdell concludes from an observation of his cases that union is 
41 



642 



TREATISE OX FRACTURES 
I 




Fig. 892. — Radiograph of the normal and injured femur for comparison. In the normal bone the 
lower epiphysis with its nucleus of bone is shown occupying its usual position. In the injured femur 
the lower epiphysis has been displaced backward and upward, its position being indicated by the 
contained ossification nucleus. The periosteum has been stripped up from the lower portion of the 
shaft of the bone and beneath this new-bone formation is already taking place. (Courtesy of 
Edward D. Truesdell, M.D., New York Lying-in-Hospital.) 




Fie. 803. — At the fourth month the new formed femur compares quite favorably with its fellow of 

te side. The now and original portions of the femoral shaft, differ but slightly in density. 

Indications of the new internal and external condyles are evident, the ossification nucleus occupying 

its usual position in the depression between them. (Courtesy of Edward D. Truesdell, M.D.. Xew 

York Lying in-Hospital.) 



BIRTH FRACTURES 643 

prompt in birth fractures of the humerus, complicating injuries are 
usually insignificant, and lateral displacement even if marked is not 
unfavorable. He thinks angular deformity should be guarded against 
or corrected if possible, but that when uncorrected and even when 
excessive, nature will do much to remedy the defect during the first 
years of life, effecting a final result never possible under corresponding 
conditions in an adult patient. Fractures of the shaft of the femur 
may do well by hyperflexing the knee and holding the limb thus with a 
bandage or an adhesive plaster strap. 

Fracture of the Clavicle — Etiology. — Of the 10 cases observed by 
Truesdell 8 occurred during version with breech extraction, i during 
forceps delivery and i during a normal vertex delivery. The latter 
was unrecognized at the time of birth, and later attention was called to 
its presence by the pressure from callus. 

The site of fracture (Fig. 890) is usually about the middle or at 





Fig. 894. — Long side splint used in fracture of shaft of femur. The use of this splint should correct 
external angular deformity and afford traction. Coaptation splints may be used about the thigh. 
(Courtesy of Edward D. Truesdell, M.D., New York Lying-in-Hospital.) 

the junction of the middle with the outer third. In most of the cases 
displacement was very slight, and in those in which it was moderate it 
assumed that seen in corresponding fractures in the adult. 

Treatment — This consisted in the majority of cases of the Velpeau 
bandage and retention in corrected position by a posterior figure-of-8 
bandage. 

Union was prompt, and occurred with the formation of visible 
callus In one case union failed to occur at the end of the fifteenth 
month, and a false joint had formed at the seat of fracture. 

Fracture of the Femur. — Two cases of fracture of the femoral 
•shaft and one of separation of the lower femoral epiphysis were 
observed by Truesdell. 

Etiology. — One of the cases of fracture of the femur occurred 
during version and breech extraction ; the other patient was delivered 
by a midwife. The delivery was spontaneous, but as the child did not 
start to breathe as promptly as was thought desirable by the attendant, 



644 



TREATISE OX FRACTURES 



it was seized by the ankles and swung about in the air with a resulting 
fracture of the femur. The separation of the lower femoral epiphysis 
occurred during internal podalic version and breech extraction. Con- 



,^- 





Fir.. 803. — Aluminum splint used in fracture of humerus. A, Part secured behind back by ad- 
hesive plaster. H. Part benind shoulder. C, and D. Flaps which fold about arm. press upper frag- 
ment inwards and lower fragment outwards. The splint is lined with canton flannel or sheet wadding. 
• of Edward D. Truesdell, M.D., New York Lying-in-Hospital.) 



siderable difficulty in delivering the after-coming head resulted in pro- 
longed manipulation of the child's body. 

The symptoms of fracture of the shaft of the femur (Fig. 891) 



BIRTH FRACTURES 645 

are those usually seen in fracture of the shaft in the adult. In the 
separation of the lower femoral epiphysis (Figs. 892 and 893) the 
lower thigh presented an appearance of an infraction and the radio- 
graph showed a dislocation of the cartilaginous lower epiphysis of the 
femur inward, outward, and backward. 

Of the fractures of the shaft, one was treated by splints and ban- 
dages without any attempt at extension. Then the patient disappeared 
from observation before union had occurred. When seen at the end of 
eighteen months, there was firm union, anterior angular deformity, 
shortening, and a decided limp. 

In the second case the fracture was not observed until one month 
after its occurrence. Union was firm, there was external and anterior 
angular deformity, shortening, and abundant callus. In the case of 
separation of the lower femoral epiphysis, full reduction of fragments 
was impossible. Callus formation occurred along the course of the 
stripped off periosteum, which was attached to the lower epiphysis and 
detached from the junction of the middle and lower thirds of the shaft 
downward. This resulted in the formation of a new shaft and con- 
dyles, with atrophy of the denuded portion of the shaft. 

Treatment. — In all fractures of the shaft of the femur, correction 
of the deformity should be performed and immobilization made with 
a suitable dressing which includes traction if necessary. A good 
dressing is that described by Truesdell (Figs. 894 and 895). The 
articles by Drs. Truesdell and Kosmak have been freely, used in the 
preparation of this chapter. 



CHAPTER XXIX 
GUNSHOT FRACTURES 

Gunshot fractures (Figs. 897-909) are relatively infrequent in 
civil life. Those seen are inflicted by accident or with homicidal or 
suicidal intent. The usual weapons are revolvers, pistols, shot-guns, 
occasionally the Flobert rifle, and very rarely the military rifle. The 
type of revolver used is generally of moderate calibre and is not as 
powerful as the heavy service weapon. Fractures by the military rifle 
occur in civil life from attempts at suicide, and as the weapon is held 
near the body the character of injury is entirely different from that 
seen in military life, where the wounds are inflicted at considerable 
distances. This statement is, however, modified by the fact that the 
firearms used by sportsmen are becoming more and more like those 
used in military sen-ice. The arms of civil life, however, probably 
have usually missiles of less weight and calibre, lower velocity and less 
energy than those of the soldier. 

The characteristics of a bullet wound depend upon the velocity of 
the missile, its size, the distance it travels before impact, its mode of 
impact, its stability, and the resistance of the part struck. 

The usual type of weapon producing fractures in civil life is the 
revolver, usually of a 32 or a 38 calibre. The projectile from this 
weapon has no great velocity, the distance travelled by the missile is 
short. The injury is often characterized by a wound of entrance with- 
out a wound of exit. There is damage in the track of the bullet, 
perhaps deformity, and the bullet, possibly fragmented or distorted by 
contact with bone, is lodged under the skin at a point opposite to the 
point of entrance. Frequently the bullet can be detected beneath the 
surface by careful palpation. 

Industrial injuries from explosions of dynamite and similar agen- 
cies represent quite well analogous fractures and wounds of soft parts 
resulting from shell and hand grenades used in war. 

Makins gives five types of fracture (Fig. 896) which are observed 
in military life: these are simulated to some extent in civil life. 

Stellate fracture : The bullet perforates the bone centrally and 
from the bullet tract four oblique fissures radiate to the surfaces of 
the bone, separating a wedge-shaped fragment from each side, and 
causing the ends of the main fragments to be pointed. This is com- 
monly termed the " butterfly " fracture. 

The irregular stellate fracture, due to low degree of velocity of 
bullet. Here there i> suppression of the two left-hand limbs with the 
substitution of a transverse line of fracture. 

646 



GUNSHOT FRACTURES 



647 



Typical complete wedge fracture. 

Incomplete wedge fracture. In this variety the line of fracture is 
oblique or lateral and the two left-hand lines of the stellate fracture 
are suppressed. 

Oblique single line fracture : In this variety one right-hand and 
one left-hand line of the stellate fracture are suppressed. The weight 
of the body probably has some influence in the production of this type. 
To fully recognize these types by radiogram the rays should be directed 
in the exact line of the track of the bullet. 

While many of the gunshot fractures may be stellate in character, 
marked comminution is present and the lateral main fragments are 
broken up into numerous smaller fragments. Perforated fractures 




Fig. 806. — Makin's five types of fracture observed in military life: A, stellate fracture; B, irreg- 
ular stellate fracture; C, typical complete wedge fracture; D, incomplete wedge fracture; and jk, 
oblique single line fracture. 

are particularly observed when the fracture occupies the epiphyseal 
end of a bone ; comminution is apt to be absent here on account of the 
small proportion of compact bone in this locality. 

The displacement of fragments in all comminuted fractures is 
toward the exit side, which is due to the propulsive effect of the bullet. 
Slight lateral displacement may also occur from the wedge- action of 
the bullet as it traverses the bone. In many of the gunshot wounds of 
civil life the fracture is characterized by little if any displacement of 
fragments, but by imbedding of the bullet in the bone and by frag- 
mentation of the bullet. In fractures produced by shotguns the distance 
travelled by the shot is very short and as a rule the shot strikes as a 
compact mass. Marked comminution of fragments is characteristic. 



648 TREATISE CN FRACTURES 

Gutter and groove fractures ma)- be considered as incomplete perfora- 
tions, the roof of the terminal being absent. They are rarely seen in 
the shaft, but more commonly in the articular ends of the bone. 

The present European 'War has served to change somewhat radi- 
cally surgeons' views in regard to gunshot wounds received in war- 
fare. The mutilating character of shell and shrapnel injuries and 
the coincident life of the soldier in trenches produce with great fre- 
quency severe comminution of bone accompanied by crushing of the 




Fig. 897. — Gunshot fracture of the palate and the body of the sphenoid bones. Wound self- 
inflicted by a 32-calibre bullet, which passed through the palate bone and lodged in the body of the 
sphenoid bone. Patient recovered. Anteroposterior view. (See Fig. 897c.) 

soft -parts and immediate infection with pyogenic and perhaps tetanus 
and gas bacillus organisms. Such lesions are comparable to machinery 
and railroad crushes of limbs so frequent in civil life. These lesions 
are air exposed, and, therefore, may be called infectious osteomyelitis 
almost from the reception of injury. The English term, " compound" 
comminuted fracture applied to open fractures of this kind, is scarcely 
descriptive, nor is infected comminuted fracture sufficient. "Infected 
pulpified fracture" might be a better term. Such injuries, whether 



GUNSHOT FRACTURES 649 

obtained in military service or otherwise, present far different prob- 
lems from other complicated fractures. 

Symptoms. — The symptoms of gunshot fracture are pain and 
shock. The former depends upon the site of fracture and of the wound 
of entrance, the sensitiveness of the individual, and the mental pre- 
occupation of the patient at the time of injury. The shock varies 




Fig. 807 a. Gunshot fracture of the palate and the body of the sphenoid bones. Wound self- 
inflicted by a 32-calibre bullet, which passed through the palate bone and lodged in the body of the 
sphenoid bone. Patient recovered. Lateral view. ^See Fig. 897.) 

greatly with the site and seriousness of the fracture. In perforated 
fractures without comminution or loss of continuity of bone, diagnosis 
will depend upon the line of the bullet and the radiographic examina- 
tion. In complete fractures there will be abnormal mobility of frag- 
ments and crepitus, which at times may be difficult to elicit on account 
of fragmentation and separation of the ends of the bone. In suspected 
fractures, radiograms in two planes should be taken. 



650 TREATISE OX FRACTURES 

Gunshot fractures depend upon the character of the projectiles. 
The modern service rifle has small calibre and projects a jacketed bullet 
of lessened diameter compared with the bullets formerly used. Thus 
the velocity of the projectile is increased, and its trajectory relatively 
flat, though the revolution of the projectile on its long axis is increased 
by reason of its length. The severity of the wound produced by this 




Fig. Sot b. — Perforating gunshot fracture of the frontal and the nasal bones. Small fragments of lead 
may be seen imbedded. 

bullet decreases in indirect proportion to the distance of the object 
struck from the muzzle of the rifle: that is. the greater the distance, 
the less the injury. The more pointed the bullet, the greater is its 
penetrating power, and its ability to perforate bone. Bullets of low 
velocity have less penetrating power than those of high velocity. Thus 
it is that les^ injury is done the greater the distance from the muzzle 



GUNSHOT FRACTURES 



651 



of the rifle. Bullets of low velocity may lodge in the tissues without 
being deformed, because they have little penetrating power. A bullet 
which strikes an object before entering the skin may richochet and, 
being deformed by the first impact, will probably cause more damage 
than a bullet which has not richocheted. Soft spongy bone allows per- 
foration by reason of its lessened resistance more readily than compact 
bone. The bullet track is like a hole bored in soft wood. Compact 
bone is more split up, and the broken particles, acting as secondary 



jH 








> 




«f* r 




. 


V 

t 


Hppi 
* 

1 " 





Fig. 898. — Gunshot fracture of the mandible. 

missiles from assuming the unexpended velocity of the arrested projec- 
tile, greatly increase the explosive effect of the bullet. 

The skin wound of entrance and that of the underlying soft parts 
may be trivial in appearance, while the bone itself is greatly damaged. 
The bone shattered into fragments may greatly lacerate the soft tissues 
near it, especially on the side opposite the point of impact. This 
corresponds with the usual well known smaller wound of entrance of 
bullets of low velocity and the greater size of the wound of exit. A 



652 



TREATISE OX FRACTURES 



missile travelling with great velocity and meeting little resistance 
makes a narrow track with small entrance and small exit wound with 
little deflection within the tissue. 

The experience of military surgeons with rifle wounds such as 
have just been described proves that the jacketed small calibre bullets 




fracture of the left humerus. The bullet is lodged in the axilla. 



of high velocity cause less dangerous wounds, though they temporarily 
disable the soldier. Smokeless powder is said to add to the humanity 
of gunshot wounds from small arms. 

Complications. — The complications of gunshot fractures are in- 
fection, and injury to blood-vessels, nerves, tendons, or muscles, or 
lesions of proximal or distal viscera. In pulpified and comminuted 



GUNSHOT FRACTURES 653 

fractures infection with pyogenic, gas bacillus and tetanus germs is 
frequent in war zones. 

The modern change in shape of bullets has influenced the character 
of the wound in bones as well as soft parts. Soft lead bullets, and 
even hardened lead bullets which are jacketed, are liable to change 
shape when striking the bone and therefore, whether deflected or per- 
forating, do more damage to hard and soft tissues. Bullets composed 
of a single piece suffer less change from contact with hard structures. 
This change in shape, when it occurs, gives rise to more splinters, a 




rfly type of fracture, and fragmentation of 

larger wound of the soft parts and bone, and by making the fragments 
of bone secondary missiles, enlarges the wound of exit more than 
would otherwise be the case. 

The extensive comminution of gunshot fractures which occurs espe- 
cially in shafts is a complication of less moment than might be expected, 
provided no primary infection occurs from particles of clothing enter- 
ing the wound, and the wounds of entrance and exit are protected 
from admitting infection from without. Primary hemorrhage, due 
to the fracturing missile, may be serious from injury to large vessels. 
The present opinion appears to be that attempts on the part of the 



654 



TREATISE ON FRACTURES 



soldier himself or non-medical attendants to apply constrictive ap- 
paratus to stop hemorrhage is unwise. The danger of unnecessarily 
severe pressure causing distal gangrene is great. This is seen also in 
civil practice from tourniquets and constriction with rubber or cotton 
bandaging for open fractures and other wounds complicated by bleed- 
ing. It would be well if non-medical attendants giving first aid remem- 
bered that stopping bleeding from a blood-vessel is usually as easy as 
stopping water escaping from a punctured hose. Slight continuous 
pressure with the finger or a pad on the opening, or broad circular con- 
striction of moderate amount with any bandage-like material about 
three inches wide is usually sufficient. Gangrene from unwise pressure 
to stop bleeding often occurs in open comminuted fractures due to gun- 
shot or industrial accidents. Ampu- 
tation would often be less exten- 
sive, or avoidable, if such pressure 
were omitted. 

In gunshot wounds, civil and 
military, tetanus is a not uncommon 
complication. Trench fighting and 
soiled hands make infection from 
its anaerobic bacillus in the ground 
an easy matter. Immediate treat- 
ment with full doses of anti-tetanus 
serum is a wise precaution. Small 
pistols used by boys for celebrating 
holidays have been accountable for 
many deaths from tetanus in 
America. Sailors' open fractures 
are said to be less frequently in- 
fected than soldiers. The less ten- 
dency to be contaminated with soil 
and by filthy contacts is evidently 
the reason for sailors' immunity. 

Prognosis. — Unless complications of a grave character occur, the 
prognosis as to life is good. Union usually is slow, and there is a 
large mass of callus found where there are many fragments. Con- 
solidation requires a long time, if there be infection. Cure may be 
accompanied by shortening, some angulation of fragments, and per- 
sistent sinuses with necrosis of fragments. These incidents depend 
largely upon the occurrence of infection or of unrelieved muscular 
displacement from spasm. 

Infection of the wound occurs in the majority of gunshot fractures 
in civil life. This is said to be unusual in military life where small 
jacketed bullets of high velocity are used. First aid aseptic dressings 




Fig. 901. — Gunshot fracture of the carpus. 



GUNSHOT FRACTURES 



655 



are often used by the wounded themselves in time of war. Infection is 
due to the septic missile, the introduction of foreign bodies with the 
bullet, such as portions of the clothing, or is carried in from the skin. 
Death is common in infected shot fractures from osteomyelitis. Espe- 
cially is this true in the pulpified fractures due to large shot, shell frag- 
ments and shrapnel. Exposure after injury, delay in first aid, careless 
and ignorant dressing and hasty operative treatment add to the fatalities 
in war times. 

Small pointed bullets, by causing small entrance wounds, relatively 
less danger of infection and less movement of fragments of clothing: 




Fig. 902. — Gunshot fracture of the carpus. 
Fig. 903. — Gunshot fracture of the proximal phalanx of middle finger. 



within the tissues, and the adoption of antiseptic and aseptic methods 
of treatment have led to less morbidity, a lowered mortality and better 
end results in gunshot wounds of bone. Such rifle wounds often heal 
with little or no sepsis, and, though markedly comminuted, may be 
expected to act like closed fractures. The prognosis, however, is quite 
different in deflected and soft-nose bullet wounds of bone and in frac- 
tures from shell and similar projectiles. These often are followed by 
infection with local phlegmons and other septic and pysemic results. 

Gunshot fractures involving joints are particularly important be- 
cause of secondary septic arthritis involving risk to joint function, 
and affording rapid absorption of toxic products. It is important 
that conservation of motion in a joint be thought of in fractures near 



656 



TREATISE ON FRACTURES 



the articulation, even if the lines of fracture do not enter the synovial 
cavity. Stiffened shoulders, elbows, wrists and ankles are crippling 
conditions, the result of such traumatisms. It is important, therefore, 
in fracture surgery of gunshots to avoid ankylosis, even if only a 
temporary fibrous one, by watching and dressing the limbs frequently. 
In shoulders as a rule, abduction of the humerus with deliberate 

attention to motion at the joint 
will do much to preserve the 
integrity of shoulder move- 
ments. Abduction there is 
better than adduction, if anky- 
losis occurs. Elbows should 
be dressed if stiffening is prob- 
able at an angle less than right 
angle. Fractures near the hip 
joint should as a rule be 
treated with some abduction 
and in extension since perma- 
nent adduction and flexion 
prevent good function. In the 
knee, when ankylosis is com- 
plete from synostosis, a lightly 
flexed posture is the most satis- 
factory. If some motion is 
expected to be obtained, per- 
manent hyperextension of the 
joint is more satisfactory than 
partial flexion ; since the mo- 
tion when allowed becomes in- 
creasingly painful and leads 
to chronic articular changes. 
The ankle should always be 
flexed at a right angle if stiff- 
ness is expected. It should be 
remembered, however, that 
• women who wear high-heeled 
let shoes do better with the ankle 
slightly extended. These de- 
leterious stiffnesses may be avoided or lessened in crippling effect by 
massage and early mobilization. This should he remembered and 
fixation appliances, permitting access to the surface of the limb for 
such manipulation be given preference. 

Treatment. — In the treatment of gunshot fractures, the civil sur- 
i should proceed on the supposition that the wound of the soft 




Fig. 904 



GUNSHOT FRACTURES 657 

parts is infected. A general anaesthetic should as a rule be used. The 
part should be shaved and the skin thoroughly scrubbed with brush, 
soap and water, followed by alcohol, 70 per cent. If there is a wound 
of exit the tract of the bullet should be irrigated with official tincture 
of iodine, a dry sterile dressing applied, the fracture reduced, and the 
part immobilized in a gypsum case. The wound should never be 
explored unless there is considerable hemorrhage or evidence of injury 
to important nerve structures, in which case the wound of entrance 




Pic. 90s. — Aeroplane bracket splint for holding arm in abduction and forearm in extension, used in 
infected open fracture of humerus with much loss of bone. (Courtesy of Dr. R. B. Osgood.) 

should be enlarged, after irrigation with tincture of iodine, all bleed- 
ing controlled with ligature, and tendons and nerves sutured with silk. 
If drainage is considered advisable, it should consist of folded rubber 
tissue, and under no consideration should gauze be used, as it simply 
acts as a plug, prevents drainage, and spreads infection. Amputation 
is seldom required in gunshot fractures in civil life. When disinfection 
of the wounded surface or the bullet track has been effected, the wound 
or wounds dressed, and replacement of fragments accomplished, 



TREATISE ON FRACTURES 



rigidity- to the broken bone should be given by retentive appliances as 
in ordinary fractures, closed, open or infected. 

LaGarde truly says that gunshot injuries are not a special depart- 
ment of surgery, but may be met by the civilian surgeon as well as his 
military colleague under similar circumstances, since the weapons used 
by the sportsman closely resemble those of the soldier. The open 
fractures of war, however, show more injury to the soft parts, more 
breaking up of bone, more inclusion of 
foreign bodies in the wound, and greater 
impairment of vitality of tissues from mole- 
cular concussion. 

While it is true that rifle wounds differ 
from those received from artillery, and that 
men fighting in trenches are more subject 
to contamination from necessarily filthy 
habits and contact with the earth ( perhaps 
under manurial cultivation for years), the 
underlying surgical principles involved are 
the same as those of industrial and other 
accidental injuries to bone. Some of the 
differences in the present war. recorded by 
surgical officers, may undoubtedly be at- 
tributed to the circumstance that die young 
surgeon of the twentieth century- has gained 
his experience almost exclusively in what 
may be called Listerian surgery. The sur- 
vivors of the old regime will doubtless 
recognize and understand, perhaps to the 
profit of their soldier patients, the necessity 
for drainage by gravity, frequent and 
copious dressings, and abundant irrigation 
in the treatment of the foul wounds and 
fractures now met on the firing line and at 
the base hospital. 

Xon-contaminated fractures should be 
managed by the prompt application of the 
first-aid dressing of the soldier and no attempt should be made to 
investigate the wound of entrance or exit with finger or probe. Fixa- 
tion by some external immobilizing dressing should be used and trans- 
portation provided as promptly as possible. The upper extremity 
may usually be immobilized temporarily by using the thorax for 
support. The lower extremity may often be similarly steadied by 
he opposite leg as a splint. These methods of temporary 
character apply to both military and non-military accidents. Foreign 




Fig. 006— " 

- 

mjiuy. (Courtesvof Dr.B. Osgood.) 



GUNSHOT FRACTURES 659 

bodies driven into the wound by the projectile should not be searched 
for on the firing line nor at the seat of accident, but allowed to remain 
until suitable time and care can be given to the study of the injury, 
and suitable fixation apparatus and definite treatment made available. 

Delorme, speaking of the expediency of extracting a metallic 
foreign body, holds that those causing neither uneasiness nor pain 
should as a rule be let alone particularly at the beginning of treatment, 
because extraction may greatly protract operation. If, however, it is 
badly tolerated or lies in contact with vessels or nerves or is situated 
in a focus of suppuration, it should be removed. A bullet that is 
discovered lying beneath the skin may be taken out, if aseptic pre- 
cautions may be obtained. 

A shell fragment that is large, irregular and sharp and also a 
shrapnel bullet, according to Delorme, must always be removed shortly 
after the injury. This in war should be done in a permanent shelter 




Fig. 907. — Gypsum encasement with basket braces of wire and gypsum-gauze for immobilization of 
infected open and comminuted fractures, in which the knee is to be kept extended. Used for frac- 
tures of femur or of tibia and fibula. (Courtesy of Dr. R. B. Osgood.) 

either at the front or in the rear of the fighting line. His reason given 
for this peremptory rule is that shrapnel wounds are so frequently 
complicated by foreign bodies carried in from the clothing. After 
removal of the metal the bottom of the wound should be methodically 
explored for materials carried in by the missile. 

It will be seen by these statements that there is a distinct difference 
between the aseptic open fractures caused by small calibre encased 
bullets and those due to hardened shrapnel bullets or irregular pieces 
of metal. The latter are accompanied by much more laceration and 
are pretty sure to be infected, as are wounds received from any sort of 
projectiles obtained during trench life. 

The danger comes from the septic contamination giving rise, in 
pulpified and comminuted bone, to an infectious osteomyelitis, which 
overshadows the loss of continuity and rigidity in the bone. After a 
patient with a gunshot wound has been transported to a base hospital, 
or brought out of the woods where he has been hunting to a fairly 
equipped modern hospital, the problem is the same. The temporary 



660 TREATISE ON FRACTURES 

immobilization is to be substituted by reduction, which previously need 

not be insisted upon, and by permanent immobilization. 

In non-infected gunshot fractures, the treatment is practically the 

same as in ordinary subcutaneous fractures or open fractures which 

have been preserved from becoming infected. 

In infected fractures, comminuted or otherwise complicated, the 

treatment is the same whether the injury be received in military or 

non-military life. 

In the severe open comminuted fractures with crushed tissues which 

above have been called " infected pulpified fractures." the treatment 
is the same for a man brought from 
filthy trenches with crushed limbs as it 
is for a man who has been wounded by 
a railroad train, a machinery crush, or 
the explosion of nitroglycerin or other 
such agents of modern industry. 

These observations mean that early 
in the case occlusion of wounds to pre- 
vent infection, the use of tetanus anti- 
toxin, prompt and efficient morphia ad- 
ministration and the use of remedies 
for shock are essential. At first tem- 
porary immobilization with any rigid 
material or with gypsum gauze splints, 

trem^i^right^G^shofeur^of tHe «* there be time and conveniences, and 

Thfba,fs^ t cTlutTbetl-"hl\Xrci t e e of careful transportation are required. 
"^rfftSSJ^SS Later, ordinary surgical principles com- 




imbedded. Vertical lines of fracture pass 

ZSLS^SSS^tS&AkvgE. bined with experience in the treatment 
(Matter Museum. Xo. 1442.01., of desperate infections will meet the in- 

dications of those cases, in which are met the burrowing abscesses, 
the absorption of pyogenic toxins, and the other results of septic or 
true pyemic infection. 

Dr. R. B. Osgood, of Boston, lays stress on the need of frequent. 
copious dressings and constant efficient drainage in the severe com- 
minuted infected bone injuries. He employed in the French hospital 
service what he terms " aeroplane " splints for the upper and " basket " 
splints of gypsum gauze and wire for the lower limb. 

The "lymph lavage" of Almroth Wright with hypertonic solution 
of 0.5 per cent, sodium citrate and 5 per cent, solution of salt, as a 
cleanser of wounds, and the coincident use of vaccine treatment may 
perhaps equal or exceed the value of the older methods of treating 
virulent bone infections. Time only will settle the question. 

Antiseptic solution, powders and oils now being employed by 
Cheyne, Carrel and others may prove efficient. It is, however, not 



GUNSHOT FRACTURES 



661 



likely that these will take the place of free incisions with trephining 
and splitting open the bone for evacuating purulent and other septic 
cavities, removal of saturated dressing every 2 or 3 hours, irrigations 
and gravity drainage. These old reliances of pre-Listerian surgery 
will probably keep their hold on those surgeons who have seen their 
efficiency. Indeed it is not improbable that the worst crushed fracture 
may be well treated with constant immersion in baths of pure water 
or mild antiseptic lotions after the manner of treating amputation 
wounds employed by F. H. Hamilton years ago. 




Fig. 909. — basket plastic splint with steel bones arranged for immobilization with extended knee 
and some traction on fracture. Applied to infected comminuted fracture of bones of leg. (.Courtesy of 
Dr. R.B.Osgood.) 



Amputations and joint resections would doubtless be rare in gun- 
shot fractures if the injured could have immediate attention at the 
hands of experienced surgeons and be given transportation of a proper 
kind and efficient after-treatment. Operative fixation with Hey 
Groves's bolting apparatus might save the limb in bad comminutions ; 
and other less complicated direct fixations will often be of service. 
Bone grafting will at times be a means of restoring function lost by 
the injury. When circumstances furnish a reasonable change, it is 
well to defer mutilating operations for gunshot fractures. 



INDEX 



Adhesive plaster dressing for maintain- 
ing Jones' position, 346 
Albee, F. H., method in the treatment of 
fractures, 109 
instruments used, no 
technic of using inlay bone grafts in 

fresh fractures, n 1 
technic of using inlay bone graft 
in ununited fractures, 112 
Albee's method of bone inlay in treat- 
ment of non-impacted fractures of the 
neck of the femur, 480 
Allis's method cf determining shorten- 
ing in fracture of neck of femur, 460 
Ambulatory treatment of fractures, 83 
advantages, 83 
disadvantages, 83 
American Surgical Association.quoted ; 
conclusions in the operative treatment 
of fractures, 114, 115 
Anaesthesia in the reduction of frag- 
ments, 59 
cocaine, novocaine, 60 
ether, 60 

nitrous oxide gas and oxygen, 60 
Anaesthesia in reduction of elbow frac- 
tures, 341 
Anaesthesia in reduction of fractures at 

lower end of radius, 407 
Ankylosis, secondary, following frac- 
tures of lower end of humerus, 342 
Arteries and veins, injury to, in frac- 
tures, 28 
Artery, middle meningeal, 117 
Artery and vein, popliteal, injury to, in 
fractures of lower end of femur, 515 
Ashhurst, A. P. C, quoted; end-results 
in fractures of lower end of humerus, 
35o 
Ashhurst, A. P. C, quoted nerve, median 
injury in fractures of lower end of 
humerus, 340 
Astragalus, 601 
etiology, 601 
prognosis, 602 
results, 605 
symptoms, 602 
treatment, 602 
varieties, 601 

Bardenheuer's method of extension, 73 
principles involved, 73 
advantages, 74 
disadvantages, 75 



Bardenheuer, quoted; statistics on clavi- 
cle fracture, 264 
Barton bandage, 201 
Barton's fracture, 392 
Barton's, reversed fracture, 393 
Battle, quoted; mortality of skull frac- 
tures, 157 
Bayonet deformity in fractures at lower 

end of radius, 404 
Beds, fracture, 58 
Bennett's fracture, 427 
Berghausen, quoted ; statistics on frac- 
tures of the vertebras, 214 
Bergmann, quoted; cerebrospinal fluid, 

amount, in basal fractures, 141 
Bergmann, quoted ; hypoglossal and 
spinal accessory nerves, injury in basal 
fractures, 144 
Bergmann, quoted ; eye changes in middle 

meningeal hemorrhage, 146 
Bergmann, quoted ; mortality of skull 

fractures, 158 
Bergmann, quoted ; operative mor- 
tality in middle meningeal hemor- 
rhage, 167 
Bladder and urethra, rupture of, in 
fractures of pelvis, symptoms of, 452 
Bladder and urethra, injury to, in frac- 
tures of pelvis, 451 
Blake, quoted ; operative mortality in 

middle meningeal hemorrhage, 167 
Bleichsteiner, quoted ; statistics on frac- 
tures of mandible, 189 
Birth fractures, 638 
clavicle, 643 
etiology, 643 
treatment, 643 
femur, 643 
etiology, 643 
symptoms, 644 
treatment, 645 
humerus, 639 
deformity, 639 
etiology, 639 
statistics, 639 
symptoms, 639 
treatment, 639 
skull, 638 
etiology, 638 
symptoms, 638 
treatment, 638 
operative, 639 

663 



664 



INDEX 



Bowen, quoted ; operative mortality in 
intracranial hemorrhage, I/O 

Bradford frame, in treatment of frac- 
tures of femur, 505 

British Medical Association, statistics of 
individual fractures as reported by 
committee of, showing results of oper- 
ative and non-operative treatment, 53 

British Medical Association, Fracture 
Committee, quoted ; cause of failure 
in operative treatment, 114 

British Medical Association, committee 
on fractures, quoted ; results in the 
treatment of fractures of the shaft of 
• the femur, 510 

British Medical Association, committee 
on fractures, quoted ; statistics of re- 
sults in fractures of neck of femur, 
480 

British Medical Association, committee 
on fractures, quoted ; results in the 
treatment of fractures of the tibia and 
fibula, 572 

Broca and Mouchet, quoted ; nerve in- 
jury in fractures of lower end of 
humerus, 340 

Brown-Sequard, paralysis, in vertebral 
fractures, 240 

Brun, Hans, quoted ; skull fractures, 132 

Bruns, quoted; showing liability of in- 
dividual bones to fracture, 1 

Bruns, quoted ; results produced by pistol 
bullet, 130 

Bruns, quoted ; statistics, failure of union 
following fractures of humerus, 319 

Bruns, quoted: nerve injuries compli- 
cating fractures, 314 
musculospiral, 314 
ulnar, 314 
radial, 314 

Bryant's vertical extension, 75 

Bryant's triangle, in determining frac- 
tures of the neck of the femur, 460 

Buck's extension, 73 

Buck's extensions in fractures of neck of 
femur, 477 

Burkhard, quoted; mortality of skull 
fractures, 157 

Burnham, A. C, quoted ; mortality in 
skull fractures, 158 

Burrell, quoted; mortality in vertebral 
fractures, 244 

Calcaneum, 605 

etiology, 605 

prognosis, 614 

statistics, 607 

symptoms, 609 

treatment, 615 
non-operative, 615 
operative, 615 

varieties. 605 
Cardiovascular changes, in fractures, 38 
Carpal bones, 417 

anatomy, 417 

diagnosis, 4-'' 



Carpal bones, etiology, 418 
statistics, 418 
surface markings, 418 
symptoms, 419 
cuneiform, 421 
scophoid, 419 
semilunar, 421 
treatment, 421 
Carrying angle (Ashurst, quoted), 350 
Cerebrospinal fluid, amount, in basal 
skull fractures, Bergmann, quoted, 141 
Cerebrospinal fluid, amount of, in skull 
(basal) fractures, MacCormac, Sir \\\, 
quoted, 141 
Cerebrospinal fluid in skull (basal) frac- 
tures, Phelps, quoted, 140 
Chauffeurs' fracture, 397 
Chipault, quoted ; operative mortality in 

vertebral fractures, 245 
Chudowsky, quoted ; showing liability of 

individual bones to fracture, 1 
Clavicle. 264 

anatomy, 264 
complications, 270 
etiology, 265 
prognosis, 271 
statistics, 264 

Freeman quoted. 264 
surface markings, 264 
symptoms, 265 
inner third, 269 
middle third, 266 
outer third, 267 
treatment, 271 

claviculo-humeral dressing, 275 
dorsal recumbency, 273 
operative, 276 
reduction in children. 271 
reduction in adults, 272 
Sayre dressing, 274 
summary of, 277 
Clavicle, statistics on fracture of, Mal- 

gaigne, quoted, 264 
Clavicle, statistics on, Pitha, quoted, 264 
Codivilla's method of nail extension. 76 
Coenen, quoted ; nerve musculospiral 
injury in fractures of lower end of 
humerus, 340 
Coler, quoted ; explosive action upon 

brain by bullet, 130 
Colles's fracture, 386, 387 
Colles's reversed fracture. 390 
Coma in head injuries, differential diag- 
nosis from other forms of uncon- 
sciousness, 155 
Complications of fractures, 28 

arteries and veins, injury to, 28 
cardiovascular, 38 
delirium, alcoholic, 37 
delirium, traumatic, 36 
dislocation, association of a, 34 
embolism, fat, 34 
infection, 35 
joints, injury to, 33 
lesions of soft parts. 28 
muscles, injury to, 31 



INDEX 



665 



Complications of fractures, nerves, in- 
jury to, 30 
pulmonic, 37 

shock and hemorrhage, 36 
symptoms, 29 

thrombosis and embolism, 35 
treatment, 30 
Concussion, cerebral, 148 
etiology of, 148 
symptoms of, 148 
Contraindications to operative treatment 
in closed fractures, 87 
those due to the fracture, 87 
those dependent upon the patient's 

general condition, 87 
those pertaining to the operator, 87 
those relating to the environment, 87 
Contusion, cerebral, 150 
location of, 150 
symptoms of, 152 
Cortors, F., method of operative im- 
paction of fragments in intercondylar 
fractures of femur, 516 
Cotton's method of palpation of anterior 
surface of bodies of cervical verte- 
brae, 214 
Cotton's method of operative impaction 
in treatment of non-impacted fractures 
of neck of femur, 479 
Cotton's method of operative reduction 

of fractures of the calcaneum, 615 
Coxa vara, traumatic, 481 
Crandon and Wilson, quoted ; hemor- 
rhage and mortality in basal frac- 
tures, 139 
Crandon and Wilson, quoted ; cerebro- 
spinal fluid in basal fractures, 140 
Crandon and Wilson, quoted ; mortality 

of skull fractures, 157 
Craniocerebral localization, 119 
Cranium (see skull), 116 
Crepitus in fractures of neck of femur, 

472 
Cubitus valgus, 345, 35° 
Cubitus varus, 345, 350 
Cullen, quoted; optic nerve injury in 

basal fractures, 142 
Cuneiform, fractures of, 421 
Cushing, quoted; location of injury in 

spinal cord lesions, 232 
Cushing, quoted ; operative mortality in 

middle meningeal hemorrhage, 167 
Cryer's method of splinting mandibular 
fractures, 201 

Decompression in fractures of skull, 161 

Definitions, 1 

Delatour, quoted ; end-results in the 
operative treatment of fractures of 
the patella, 536 

Delayed union, 26 

Delirium, alcoholic, in fractures, 37 

Delirium, traumatic, in fractures, 36 

Delorme, quoted; treatment of imbed- 
ded particles in gunshot fractures, 659 



Dejerine, quoted; relationship of seg- 
ments of spinal cord and nerve roots to 
bodies and spines of vertebra, 226, 230 

Destot, Vignard and Barlatier, quoted ; 
nerve injury in fractures of lower end 
of humerus, 340 

Diagnosis, differential, 22 ; general, 21 

Diaphysis and epiphysis, rules of bony 
union of, Gerrish, quoted, 39 

Disability, average period of, in sub- 
cutaneous fractures as reported by 
the committee of the B. M. A., 56 

Disability following fractures, Estes, 
W. L., quoted, 56 

Diseases, constitutional, in the preven- 
tion of union, 107 

Dislocation, adjacent, associated with a 
fracture, 34 

Dislocation, definition, 1 

Displacement of fragments, 16 
absence of, 16 
etiology of, 17 
varieties of, 16 

Duchain, quoted ; operative mortality in 
middle meningeal hemorrhage, 167 

Dwight, quoted ; hemorrhage in basal 
fractures, 139 

Dwight, quoted ; hemorrhage from mid- 
dle meningeal in skull fractures, 144 

Eguchi, quoted ; epilepsy, traumatic, fol- 
lowing skull injuries, 158 
Epiphyseal separations, 38 
anatomy, 38 
complications, 49 
date of ossification and time of 

union with diaphysis, 39 
diagnosis of, 49 
etiology, 46 
occurrence, 47 
radiographic findings, 49 
sequelae, 49 
symptoms, 48 
treatment, 49 
Epiphysis, separation of lower radial, 

390 
Epilepsy, traumatic, following skull in- 
juries, Eguchi, quoted, 158 
Estes, quoted ; statistics showing period 

of disability in open fractures, 56 
Etiology of fractures, 6 
exciting causes, 7 
predisposing causes, 6 
Eversion and inversion in fractures of 

neck of femur, 471 
Extension or traction dressings and 
methods, 73 
Buck's extension, 73 
Bardenheuer's method, 73 
Bryant's method of vertical exten- 
sion, 75 
Steinmann's method of nail exten- 
sion, 76 
Codivilla's method of nail extension, 

76 
Zuppinger's method of extension, 78 



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INDEX 



667 



Freeman, quoted; statistics on fractures 
of clavicle, 264 

Functional impairment and loss of earn- 
ing capacity, 57 

Functional results in relation to ana- 
tomical results, 61 

Functional treatment of fractures, 82 

Gangrene in fractures, 30 
General considerations, 1 
Gerrish, quoted; rules of bony union of 

the diaphysis and epiphysis, 39 
Gibbs, quoted ; statistics on fractures of 

hyoid, 205 
Gunshot fractures, 8, 646 
complications, 652 
displacement of fragments, 647 
prognosis, 654 

shell and shrapnel injuries, 648 
symptoms, 649 
treatment, 656 
types of fractures, 646 
types of projectiles, 650 
Gunshot fractures of skull, 127 
lesion produced, 127, 130 
skull, 129, 130 
brain, 131 
Gurlt, quoted ; statistics on fractures of 
mandible, 189 
statistics on fractures of hyoid, 205 

Hanging, judicial, type of fracture of 
vertebrae in, Wood-Jones, quoted, 223 
Hemothorax in rib fractures, 260 
Haenel (quoted by von Bergmann) ; re- 
sults after malleolar fractures, 587 
Haldenwang, quoted ; statistics on frac- 
tures of the neck of the femur in 
childhood, 463 
Hawley's traction table, 91 
Heer, Anna, quoted ; cerebrospinal fluid 

in basal fractures, 140 
Heer, Anna, quoted; facial nerve injury 

in basal fractures, 143 
Hemorrhage, intracranial, in fractures 
of the skull, 144 
etiology, 144 
source, 144 
internal carotid, 147 
intracranial sinuses, 146 
middle meningeal, 144 
amount, 144 

blood-pressure changes, 145 
diagnosis, 144 
eye changes, 146 
hematomas, resulting, 144 
pulse changes, 145 
respiratory changes, 146 
mortality, operative, Bowen, quoted, 
170 
Hemorrhage, middle meningeal, 144 
cause of death, 167 
eye, changes in, Bergmann, quoted, 

146 
Kronlein's points of election for 
trephining, 145, 166 



Hemorrhage, middle meningeal, mor- 
tality, operative, Bergmann, 
quoted, 167 
mortality, operative, Blake, quoted, 

167 
operative mortality, Cushing, quoted, 

167 
operative mortality, Duchain, 

quoted, 167 
in skull (basal) fractures, Dwight, 

quoted, 144 
treatment of, i65 
Hemorrhage, prearachnoid, 147 

in fractures of skull, treatment of, 
170 
Ha;matomas in middle meningeal 

hemorrhage, Kronlein, quoted, 144 
Hennequin, quoted ; results in supracon- 
dylar fracture of the femur, 513 
Hernia of the lung in rib fractures, 261 
Hitzrot, quoted ; results in fracture of 
head of radius, 381 
results in fracture of neck of 
radius, 383 
Hoffmann, quoted ; mortality in fractures 
of cartilage of larynx and trachea, 
210 
statistics on fractures of cartilage of 
larynx and trachea, 208 
Hoffmann and Lesser, quoted; statistics 
on fractures of cartilage of larynx 
and trachea, 209 
Holder, quoted; injury to optic foramen 

in basal fractures, 142 
Humerus, fractures of, 290 
anatomy, 290 
surface markings, 291 
statistics, 292 

upper end of humerus, 294 
varieties, 294 
head, 295 
etiology, 295 
symptoms, 295 
treatment, 295 
anatomical neck, 296 
etiology, 296 
symptoms, 296 
diagnosis, 296 
prognosis, 296 
treatment, 296 
tuberosities through, 297 
etiology, 298 
symptoms, 298 
treatment, 298 
tuberosity, isolated of greater, 
299 
etiology, 299 
symptoms, 300 
diagnosis, 300 
treatment, 300 
tuberosity, isolated of lesser, 300 
symptoms, 300 
diagnosis, 301 
treatment, 301 



668 



INDEX 



Humerus, fractures of, . 
upper end of humerus, 
varieties, 

epiphysis, separation of upper, 

etiology, 301 

symptoms, 301 

diagnosis, 303 

treatment, 305 

after results, 305 
surgical neck, 306 

etiology, 307 

symptoms, 308 

diagnosis, 309 

complications, 309 

treatment, 309 

after results, 312 
shaft of humerus, 313 
etiology, 313 
symptoms, 313 
diagnosis, 313 
complications, 313 

musculospiral nerve injury, 314 
treatment, operative, 316 
treatment, 316 
after results, 318 

failure of union, 319 

pseudarthrosis, 319 
lower end of humerus, 319 
etiology, 319 

forms found in childhood, 319 
forms found in adults, 319 
varieties, 319 
supracondylar, 322 

statistics, 322 

varieties, 322 

symptoms, 323 

diagnosis, 324 

mechanism of fracture. 322 
diacondylar, 324 

mechanism of fracture, 324 

symptoms, 324 

diagnosis, 326 
intercondylar, T, Y, or atypical, 
326 

etiology, 326 

symptoms, 327 

diagnosis, 327 
epiphvsis, separation of lower, 
328 

anatomy, 328 

etiology, 328 

symptoms, 328 

diagnosis, 330 
epicondyle, external. 331 

etiology, 331 

symptoms, 33T 
condyle, external, 331 

etiology, 332 

symptoms, 332 
capitelhnn, 333 

etiology, 333 

symptoms, 333 
epicondyle, internal, 334 

etiology. 314 

symptoms, 335 

diagnosis, 335 



Humerus, fractures of, 

lower end of humerus, 
varieties, 

condyle, internal, 335 
statistics, 335 
etiology, 336 
symptoms, 336 
diagnosis, 336 
trochlea, 336 
etiology, 338 
symptoms, 338 
complications of fr. lower end of 
humerus, 338 
open fractures, 338 
Volkmann's ischsemic contrac- 

ture,338 
blood-vessel injuries, 340 
nerve injuries, 340 
statistics, 340 
treatment, 340 
treatment, 340 
anaesthesia, 341 
ankylosis, 342 
reduction, 342 

hyperflexion and supination, 
T 343 

Jones' position, 343 
right angle anterior splint, 344 
cubitus varus, 345, 350 
cubitus valgus, 345, 350 
after results, 349 
treatment, operative, 351 
summary of treament, 352 
Hyoid, 205 

anatomy, 205 
complications, 206 
diagnosis, 207 
etiology, 205 
prognosis, 207 
statistics, 205 
surface markings, 205 
symptoms, 206 
treatment, 207 
Hyoid, statistics on, Gibbs, quoted, 205 
Gurlt, quoted, 205 

Immelmann, quoted ; liability of indi- 
vidual bones to fracture, 1 

Immobilization, temporary, of frag- 
ments, 58 

Impairment of motions in fractures of 
neck of femur, 470 

Indications for operative treatment, 
closed fractures, 86, 88 

Infection in fractures, 28 
in closed fractures, 35 
in open treatment oif closed frac- 
tures, 86 

Infolding fracture of lower end of 
radius, 393 

Internal carotid hemorrhage, T47 

Internal carotid, hemorrhage from, in 
skull fractures, treatment of, 170 

Intracranial sinuses hemorrhage, 746 

Intracranial sinuses, hemorrhage from, 
treatment of, 167 



INDEX 



669 



Intrapartum fractures, 11 
Intrauterine fractures, 10 
Inversion fracture of fifth metatarsal, 

625 
Ischemic muscular atrophy, 31, 32 
etiology, 32 
symptoms, 32 
treatment, 33 
mechanical, after, 33 
operative, 33 
preventive, 33 
Jensen, J., quoted ; statistics on frac- 
tures of pelvis, 436 
Joints, injury to neighboring, in frac- 
tures, 33 
Jones, R., position in treatment of frac- 
tures of lower end of humerus, 343 
use of the Thomas knee splint in the 
treatment of fractures of the 
shaft of the femur, 506 
quoted; use of Thomas knee splint 
in treatment of fractures of lower 
end of femur, 516 

Katzenelson, quoted; anatomy of pelvic 
archs in relation to lines of fracture, 438 , 
Kocher, quoted ; classification of verte- 
bral fractures, 216 
location of fractures of bodies of 
vertebrae, 217 
Kocher's classification of supracondylar 

fractures of humerus, 322 
Kohler, quoted; facial nerve injury in 

basal fractures, 143 
Kosmak's method of correction of de- 
pressed skull fractures, 638 
Kronlein's points of election for trephin- 
ing in middle meningeal hemorrhage, 
145, 166 
Kronlein, quoted; haematomas in middle 

meningeal hemorrhage, 144 
La Garde, quoted; gunshot injuries, 658 
Lane's plates in fractures, 96 
technic of application, 96 
Larynx and trachea, cartilages of, 208 
anatomy, 208 
complications, 210 
etiology, 209 
prognosis, 210 
statistics, 208 
surface markings, 208 
symptoms, 209 
treatment, 210 
Larynx and trachea, cartilages, mor- 
tality on, Hoffmann, quoted, 210 
statistics on, Hoffmann, quoted, 208 
Lente, quoted ; statistics on fracture of 

mandible, 189 
Lerda and Quenu, quoted ; use of co- 
caine and novocaine in reduction of 
fractures, 60 
Ligament of the patella, rupture of, 539 
etiology, 539 
prognosis, 539 
symptoms, 539 
treatment, 539 



Liston T-splint, 504 

Lloyd, Samuel, quoted; operative mor- 
tality in vertebral fractures, 245 

Lothrop's, H. A., method of reduction in 
depressed malar fractures, 183 

Lowman's bone clamp, in fractures, 98 

Lumbar ouncture in fractures of skull, 
161 

MacCormac, Sir W., quoted ; cerebro- 
spinal fluid, amount, in basal frac- 
tures, 141 
Makin's types of gunshot fractures, 646 
Malar bone, 180 
anatomy, 180 
complications, 182 
diagnosis, 182 

methods of examination, 180 
prognosis, 183 
surface markings, 180 
symptoms, 182 
treatment, 183 
varieties of fracture, 180 
Malgaigne, quoted ; statistics on clavicle 

fractures, 264 
Malgaigne, double vertical fracture of 

pelvis, 440 
Malleolar fractures, results after, 
Haenel (quoted by v. Bergmann), 587 
Mandible, 188 

anatomy, 188 

complications, 196 

diagnosis, 198 

etiology, 190 

methods of examination, 194 

prognosis, 199 

statistics, 188 

Gurlt, quoted, 189 
Lente, quoted, 189 
surface markings, 188 
symptoms, 194 
treatment, 199 

reduction of fragments, 200 
retention of fragments, 200 
external dressings, 201 
interdental splints, 202 
mandibulomaxillary splints, 203 
suture, wire, 204 
Martin, E. A., quoted : rapid fall of 
blood-pressure in application of trac- 
tion, 106 
Massage and passive motion, in the 

treatment of fractures, 81 
Matas' method of reduction of depressed 

fractures of zygomatic arch, 184 
Maxilla, superior, 185 
anatomy, 185 
complications, 186 
diagnosis, 186 

methods of examination, 185 
prognosis, 187 
surface markings, 185 
symptoms, 186 
treatment, 187 
varieties, 185 
Menard, quoted ; statistics on fractures 
of the vertebrae, 214 



6 7 o 



INDEX 



Metacarpal bones, 422 
anatomy, 422 
diagnosis, 428 
etiology, 426 
results, 430 
statistics, 422 
surface markings, 422 
symptoms, 426 

first metacarpal, 426 
second to fifth metacarpals, 428 
treatment, 429 
Metatarsal bones, 622 
anatomy, 622 
etiology. 622 
prognosis, 625 
statistics, 622 
surface markings, 622 
symptoms, 622 
treatment, 625 
Middle meningeal, hemorrhage, 144 

treatment of, 166 
Muhlenberg and Berenger-Feraud, 
quoted: pseudarthrosis in fractures of 
mandible, 199 
Muscular relaxation in fractures of 

neck of femur, 470 
Muscular system, injury to, in frac- 
tures, 31 

Nasal bones. 172 
anatomy, 172 
complications, 177 
diagnosis, 176 

displacement of fragments, 174 
etiology, 174 

methods of examination, 176 
prognosis, 177 
symptoms, 176 
treatment, 177 

old unreduced fractures, 179 
recent fractures, 178 
varieties, 174 
Nerve (abducens). injury in skull 
(basal) fractures, Schroder, quoted, 
143 
Nerves, cranial, involved, in basal frac- 
tures, 142 
anterior fossa, 142 
middle fossa, 142 
posterior fossa, 143 
Nerve (facial), injury, in skull (basal) 
fractures, Heer, Anna, quoted, 143 
Nerve (facial), injury, in skull (basal) 

fractures, Kohler, quoted, 143 
Nerve, hypoglossal, injury in skull 
(basal) fractures, Stierfein, quoted, 
144 
Nerves, hypoglossal and spinal acces- 
sory, injury to, in basal skull frac- 
ture's, v. Bergmann, quoted, 144 
Nerve median, injury of, in fractures of 
lower end of humerus, Ashhurst, 
\ I'. <".. quoted, 340 
Nerve, musculospinal, injury, in frac- 
tures of lower end of humerus, 
Cocnen, quoted, 340 



Nerve, musculospiral, injury, in frac- 
tures of shaft of humerus, 314 
Nerve, musculospiral paralysis, 314 
primary paralysis, 314 
intermediate paralysis, 314 
secondary paralysis, 314 
reactions of degeneration, 315 
treatment, 316 
operative, 316 
Nerve (optic), injury, in basal skull frac- 
tures, Cullen, quoted, 142 
Nerve, popliteal, injury to, in fractures 

of the lower end of femur, 515 
Nerves, injury to, in fractures, 30 
Nerve injuries complicating fractures, 
314 
musculospiral, 314 
radial, 314 
ulnar, 314 
Nerve injury complicating fractures of 
the lower end of humerus, 340 
statistics, 340 
treatment, 340 
Nerve injury, in fractures of lower end 
of the humerus, Destot, Vignard and 
Barlatier, quoted, 340 
Nerve injury, in fractures of lower end 
of the humerus, Broca and Mouchet, 
quoted, 340 
Nerve, injury to, in fracture of pelvis, 

452 
Nichols, E. H., quoted ; hemorrhage 
from middle meningeal in skull frac- 
tures, 144 
Non-union, 27 

in fractures of mandible, Norris, 
quoted, 199 
Norris, quoted ; non-union in fractures 
of mandible, 199 

Oliver, J. C, quoted ; mortality in verte- 
bral fractures, 245 
Open (compound) fractures, 79 
treatment of, 79 
types of, 79 

conservative treatment, 79 
wisdom of primary suture or plat- 
ing of fragments, 80 
Operative procedures for fractures of 

vault of skull, 162 
Osgood, quoted ; treatment of gunshot 

fractures, 660 
Optic foramen, injury to, in skull (basal) 
fractures, Holder, quoted, 142 

Paralysis, Brown-Sequard, in vertebral 

fractures, 240 
Paralysis, motor, in vertebral fractures, 
228 
sensory, in vertebral fractures, 230 
Passive motion, in fractures about el- 
bow, 347 
Patella, 525 

anatomy, 525 
diagnosis, 530 
diagnosis, differential, 530 



INDEX 



671 



Patella, etiology, 525 
prognosis, 530 
statistics, 525 _ 
surface markings, 525 
symptoms, 529 
treatment, 531 

non-operative, 532 
operative, 532 
results, 535 
results, end, 536 
varieties and mechanisms, 528 

rupture of quadriceps, extensor 

tendon of, 537 
rupture of patella ligament, 539 
Patella, ligament of, rupture of, 539 
etiology, 539 
prognosis, 539 
symptoms, 539 
treatment, 539 
Patella, refracture of, 536 
Patella, results of operative treatment, 

Dclatour, quoted, 536 
Patella, results after treatment, Quinby, 

W. C, quoted, 535 
Patella, old fracture of, 536 
Pathologic fractures, 9 
aneurysms, 10 
inflammatory processes, 9 
new growths. 10 

resulting from a general disease, 10 
Pelvic arches, anatomy of in relation to 
lines of fracture, Katzenelson, quoted, 
438 
Pelvis, 435 

anatomy, 435 

character of fracture, 437 
complications, 451 
injury to bladder and urethra, 451, 
. 452 

injury to blood-vessels, 452 
injury to nerves, 452 
etiology, 437 
prognosis, 454 
statistics, 436 
surface markings, 435 
symptoms, 447 
treatment, 455 

of the complications, 455 
of the fracture, 455 
varieties of fracture, 439-445 
Pelvis, statistics on fractures of, Jensen, 

J., quoted, 436 
Phalanges of foot, 629 
etiology, 629 
symptoms, 629 
treatment, 629 
Phalanges of hand, 431 
anatomy, 431 
diagnosis, 433 
etiology, 431 
statistics, 431 
symptoms, 431 
treatment, 433 
results, 434 
Phelps, quoted: cerebrospinal fluid in 
basal fractures, 140 



Pia-arachnoid hemorrhage, in fractures 

of skull, treatment of, 170 
Pitha, quoted; statistics on clavicle frac- 
tures, 264 
Plagemann, quoted ; liability of indi- 
vidual bones to fracture, 1 
Pneumothorax, in rib fractures, 260 
Posture in bed, in vertebral fractures, 

227 
Pott's fracture, 578 
Prearachnoid hemorrhage, 147 
Priapism, in vertebral fractures, 236 
Prognosis, general, in fractures, 51 
Pseudarthrosis in fractures of mandible, 
Muhlenberg and Berenger-Feraud, 
quoted, 199 
in fractures of neck of femur, 475 
following fractures of shaft of 
humerus, 316 
Pulmonic complications in fractures, 37 

Quadriceps extensor tendon of patella, 
rupture of, 537 
etiology, 537 
prognosis, 538 
symptoms, 537 
treatment, 539 
Quinby, W. C, quoted ; operative and 
non-operative results in the treatment 
of fractures of the patella, 535 

Radiographic examination as a guide in 
treatment, 57 
epiphyseal separations, 49 
Radius and ulna, 353 
anatomy, 353 
statistics, 355 _ 
surface markings, 355 
upper end, 356 

Radius and ulna, combined, 356 
complications, 360 
diagnosis, 360 
displacements, 358 
etiology, 356 
results, 363 
statistics, 356 
symptoms, 359 
treatment, 360 

non-operative. 360 
operative, 363 
ulna, isolated fractures of, 364 
statistics, 364 
olecranon process, 364 
displacements, 365 
etiology, 364 
results, 370 
symptoms, 367 
treatment, 368 

non-operative, 368 
operative, 370 
coronoid process, 371 
displacements, 373 
etiology, 371 
mechanism, 372 
results, 374 
symptoms, 373 
treatment, 273 



072 



IXDEX 



Radius and ulna. 
ulna, shaft ; 
displacements. 375 
etiology. 374 
symptoms. 375 
~ : 
radius, isolated fractures of, 376 
statistics. 376 
head of radius. 377 
displacement- ~ 

-. '-" 
results. 380 
symptoms. 379 
treatment, 379 
non-operativ 
operative. 379 
epiphysis, separation of upper, 

381" 
epiphysis, fracture of upper. 3S1 
neck of radi: 

displacements. 382 
etiology. 382 
results $83 
symptoms. 382 
treatrr.r: 
radius, shaft of, 383 
displacement- ^ 
etiology, 383 
symptoms. 384 
treatrr.T: : 

radius, lower end. 386 
diagnosis. 402 
diagnosis, differential. 405 
etiology. 386 
results. 414 
statistics. 386 
symptoms, 397 
treatment. 407 
anaesthesia. 407 
reduction. 407 
retention. 408 
splints. 408-412 
after treatment. 413 
summary of treatment. 415 
varieties of fractu^ 
Radius, head of, results in fracture of, 
Hitzrot quoted. 381 
neck of. results in fracture of, Hitz- 
rot. quoted. 383 
Rawling, quoted : cerebrospinal fluid in 
basal fractures. 140 
deductions in head injuries from 

temperature changes 
escape of brain tissue in basal frac- 
tures. 141 
eye changes in middle meningeal 

hemorrhage. 146 
hemorrhage from middle meningeal 

in skull fractures. 144 
mortality of skull fractup - : " 
mortality of skull fractures in rela- 
tion to temperature chan.. 
Rawlinc's rules as to the probable line 
of transbasal fracture. 134 



Reduction of fragments. 58 
anesthesia. 58. 60 
obstacles to reduction, 60 
methods of reduction, 60 
non-operative, 60 
operative. 00 
time of reduction, 60 
Reflexes, disturbance of. governing blad- 
der and rectum, in vertebral frac- 
tures, 235 
in vertebral fractures, 233 
Reid's base line. 119 
Relationship to age. sex. and season. 6 
Remer. quoted : statistics on fractures 
of cartilages of larynx and trachea, 209 
Repair of fractures. 23 

in recent closed fractures. 23 
in recent open fractures. 2; 
in recent closed fractures treated by 
aseptic operation. 25 
Results in fractures of lower end of 
humerus. Ashhurst, A. P. C, quoted. 
330 
Results in treatment of fractures of neck 
of femur. British Medical Association, 
fracture committee, quote d - 
Results in treatment of fractures of 
shaft of the femur. British Medical 
Association, fracture committee, 
quoted. 510 
Results in treatment of fractures of tibia 
and fibula, British Medical Associa- 
tion, fracture committee, quoted. 572 
Retention of fragments. 61 
temporary dressings. 62 
permanent dressings. 62 
Retentive dressings in fractures. 62 
fixation dressings. 62 
traction dressings. 62 
fixation and traction dressings. 63 
Retentive dressings, rules to be observed 

in the application of. 63 
Reversed Barton's fracture, 
Reversed Colles's fracture. 390 
Ribs and costal cartilages. _ :: 
anatomy. 256 
statistics. 256 
surface markings, 256 
ribs. 256 

complication s _ : 
intrathoracic. 258 
intraabdominal, 261 
diagnosis. 261 
etiology. 256 
pathology. 256 
prognosis. 262 
symptoms. - : " 
treatment. 262 
varieties. 256 
costal cartilages. 263 
diagno- ; - - 
etiology. 263 

sis, 263 
symptoms, ?'\t 
treatment. 263 



INDEX 



673 



Rontgen rays in diagnosis of fractures, 
22 
in diagnosis and treatment, 85 
Roser-Nelaton line in determining frac- 
tures of the neck of the femur, 459 
Ruth-Maxwell method in treatment of 
fractures of neck of femur, 478 

Sayre dressing, 274 
Scaphoid, carpal, fractures of, 419 
Scaphoid (tarsal), 616 
etiology, 616 
prognosis, 621 
symptoms, 618 
treatment, 621 
Scapula, fractures of, 278 
anatomy, 278 
surface markings, 278 
statistics, 278 
body of scapula, 279 

etiology, 279 

prognosis, 280 

symptoms, 279 

treatment, 281 

varieties, 279 
superior angle of scapula, 281 

etiology, 281 

symptoms, 282 

treatment, 282 

varieties, 282 
inferior angle of scapula, 282 

etiology, 282 

symptoms, 282 

treatment, 283 
spine of scapula, 283 

etiology, 283 

symptoms, 284 

treatment, 284 

varieties, 284 
acromion process of scapula, 284 

etiology, 284 

prognosis, 285 

symptoms, 285 

treatment, 285 

varieties, 284 
neck of scapula, 285 

diagnosis, 287 

etiology, 286 

symptoms, 286 

treatment, 287 

varieties, 285 
coracoid process of scapula, 287 

etiology, 287 

symptoms, 288 

treatment, 288 

varieties, 288 
rim of glenoid cavity of scapula, 288 

etiology, 288 

symptoms, 289 

treatment, 289 

varieties, 289 
Schroder, quoted ; abducens nerve injury 

in basal fracture, 143 
Semilunar, fracture of, 421 
Sesamoid (small) bones, 631 



Sesamoid, anatomy, 631 
etiology, 636 
statistics, 633 
symptoms, 637 
treatment, 637 
Sherman's plates in fractures, 96 

screws, 98 
Shepherd's fracture, 633 
Shock and hemorrhage in fractures, 36 
Shortening in fractures of the neck of 
the femur, 472 
methods of determining shortening, 
472 
Silver-fork deformity in fractures at 

lower end of radius, 397 
Skull, 116 

anatomy, 116 

base of skull, divisions, 119 
craneocerebral localization, 119 
density and rigidity of skull, 120 
fissures, 118 
landmarks, 116 
diagnosis, 155 
diagnosis, differential, 156 
etiology, 121 

general considerations, 116 
cerebral contusion, 150 

symptoms, 152 
hemorrhage, intracranial, 144 
amount, 144 
diagnosis, 144 
etiology, 144 
source, 144 
injury to brain, 147 

cerebral concussion, 148 
symptoms, 148 
temperature changes, 148 
mechanism of fracture at base, 
132 
Aran's theory of irradiation, 133 
bursting theory, 133 
contrecoup theory, 134 
Rawling's theory of direct vio- 
lence, 134 
mechanism of fracture at vault, 

132 
mortality, 157 
prognosis, 156 

symptoms of fracture at base, 138 
brain tissue, 141 
cerebrospinal fluid, 140 
cranial nerves, 142 
emphysema, 141 
hemorrhage, 138 
anterior fossa, 138 
middle fossa, 139 
posterior fossa, 139 
symptoms of fracture of vault, 137 
temperature changes, 148 
Skull, fractures of, 
treatment, 159 
general, 159 

decompression, 161 
lumbar puncture, 161 
venesection, 160 



674 



INDEX 



Skull, fractures of the vault, 161 
operative procedures for, 162 
fractures of the base, 165 
intracranial hemorrhage, 166 
middle meningeal, 166 
intracranial sinuses. 167 
internal carotid. 170 
pia-arachnoid. 170 
types of fracture, 121 
Skull fractures, Brun (Hans), quoted, 

132 
Skull (basal) fractures, cerebrospinal 
fluid in. Crandon and Wilson 
140 
Heer. Anna, quoted, 140 
Skull fractures, depressed. Kosmak's 

method of correction of. 638 
Skull injuries, epilepsy, traumatic follow- 
ing, Eguchi. quoted. 158 
Skull (basal) fractures, hemorrhage in, 

Dwight, quoted. 139 
Skull (basal) fractures, hemorrhage in, 

Fleming, quoted. 139 
Skull (basal) fractures, hemorrhage and 
mortality in. Crandon and Wilson, 
quoted, 139 
Skull fractures, mortality of, Battle, 
quoted, 157 
Bergmann, quoted, 158 
Burkhard, quoted. 157 
Burnham, A. C, quoted. 158 
Crandon and Wilson, quoted. 157 
mortality in relation to temperature 
changes. Rawling, quoted. 158 
Smith's fracture, 390 

Soft parts, injury to, overlying, in frac- 
tures, 28 
Spinal cord lesions, location of injury, 

Cushing, quoted, 232 
Spinal cord segments and their nerve 
roots, relationship of, to the bodies and 
spines of the vertebra?, Dejerine, 
quoted, 226, 230 
Sprain-fracture, lower end of radius. 395 
Splint, right angle anterior, in treatment 
of fractures of lower end of humerus, 
344 
Splints, angle, 187 
Hammond. 187 
Gunning, 187 
Goffre and Grafe. 187 
Splints. Cabot's posterior wire, use of, in 

fractures of bones of leg, 565 
Splints, finger. 434 
Splints. Lewis metal chin, 201 
angle, 202 
Cryer, 201 
Gunning, for mandible fractures, 

201 
Hammond. 202 

Hern, for mandible fractures, 201 
Hohl, 202 

interdental splints. 202 
Martin. 202 
Satu-r. 202 
Schauber, 202 



Splints, metal, 64 
aluminum, 64 
wire, 64 
wire gauze. 64 
tin, perforated, 64 
zinc, perforated, 64 
Spints, moulded. 65 
celluloid, 65 
felt, poroplastic, 65 
leather, 65 
Splints, nasal, 179 
Splints, plaster-of-Paris. 65 
advantages of, ~J2 
encasements, 65 
for fracture of clavicle, 66 
for fractures of upper extremity, 67, 

68 
for fractures of lower extremity, 69- 

71 • 
for shoulder cap, 66 
method of using. 68 
moulded " contour." 65 
use in open fractures, 72 
Velpeau dressing. 66 
Splints, pillow and side, in treatment of 

fractures of bones of leg, 564 
Splints, types of, 64 
Splints, use of gypsum case in treatment 

of fractures of bones of leg, 564 
Splints, wood, 64 
Sprain, definition, I 
Sprain-fracture. I 

of lower end of radius, 395 
Statistics, general, 52 

birth fractures. Truesdell. E. S.. 

quoted. 638, 639 
Chudowsky. quoted : skull fractures. 
121 
clavicle, 264 
humerus, 292 
radius and ulna, 355 
ribs, 256 
scapula, 278 
sternum, fractures. 251 
failure of union following fractures 
of humerus, Bruns. quoted. 319 
Immelmann, quoted ; clavicle frac- 
tures. 264 
humerus. 292 
scapula. 278 
radius and ulna. 355 
of British Medical Association, frac- 
ture committee, results of oper- 
ative and non-operative treatment, 
S3 
on fractures of clavicle, Barden- 

heuer. quoted, 264 
on fractures of mandible, Bleich- 

steiner. quoted. 189 
on fractures of the vertebra*, Berg- 

hausen, quoted, 214 
on open fractures, showing peril id of 
disability. 56 

T2I 

Plagemann, quoted ; skull fractures, 



INDEX 



675 



Statistics, Plagemann quoted, 

calcaneum, 607 

carpal bones, 418 

clavicle, 264 

femur, 462, 494 

humerus, 292 

metacarpal bones, 422 

metatarsals, 622 

patella, 525 

pelvis, 436 

phalanges of hand, 431 

radius, lower end, 386 

radius and ulna, 355, 356 

radius, 376 

radius, shaft, 383 

ribs, 256 

scapula, 278 
shaft, SSS 

sternum, 251 

tarsal bones, 601 

tibia and fibula, upper end, 542 

tibia shaft, isolated, 572 

tibia and fibula, lower end, supra- 
malleolar, 575 

ulna, 364 
showing liability of individual bones 

to fracture, 1 
sesamoid (small) bones, Fawcett, 
quoted, 633 
Geist, quoted, 633 
Pfitzner, quoted, 634 
Bruns, quoted, skull fractures, 121 

clavicle, 264 

humerus, 292 

radius and ulna, 355 

ribs, 256 

scapula, 278 

sternum fractures, 251 
Steinmann's method of nail extension, 76 
modifications of method, 76 
value of method, 76 
disadvantages of method, 77 
technic of applications, 77 
Sternum, 252 
anatomy, 251 
complications, 253 
diagnosis, 253 
etiology, 251 
prognosis, 253 
statistics, 251 
surface markings, 251 
symptoms, 252 
treatment, 254 
varieties, 252 
Stierlein, quoted ; hypoglossal nerve in- 
jury in basal fractures, 144 
Stimson, quoted ; statistics on fractures 
of cartilages of larynx and trachea, 209 
Symptomatology, general, 17 
constitutional, 21 
objective, 18 
subjective, 20 

Tarsal bones, 599 
anatomy, 599 
statistics, 601 



Tarsal bones, surface markings, 600 
astragalus, 601 
etiology, 601 
prognosis, 602 
results, 605 
symptoms, 602 
treatment, 602 
varieties, 601 
calcaneum, 605 
etiology, 605 
prognosis, 614 
statistics, 607 
symptoms, 609 
treatment, 615 
non-operative, 615 
operative, 615 
varieties, 605 
scaphoid, 616 
etiology, 616 
prognosis, 621 
symptoms, 618 
treatment, 621 
Temperature changes in head injuries, 

148 
Tendon of quadriceps extensor, rupture 
of, 537 
etiology, 537 
prognosis, 538 
symptoms, 537 
treatment, 539 
Thrombosis and embolism, in fractures, 

35 
Thomas, T. T., quoted ; results in frac- 
tures of head of radius, 380 
Thorburn, quoted ; operative mortality in 

vertebral fractures, 245 
Tibia, avulsion of tubercle, 553 
anatomy, 553 
etiology, 553 
symptoms, 553 
treatment, 554 
Tibia, and fibula, fractures of, 540 
anatomy, 540 
surface markings, 541 
statistics, 542 
Tibia and Fibula : 

lower end, fibular malleolus, isolated, 
595 
etiology, 595 
prognosis, 596 
symptoms, 596 
treatment, 596 
fibular malleolus and posterior ar- 
ticular edge of tibia, 588 
etiology, 588 
mechanism, 588 
prognosis, 589 
symptoms, 589 
treatment, 590 
fibula and external articular edge 
of tibia, 590 
etiology, 590 
mechanism, 590 
prognosis, 590 
symptoms, 590 
treatment, 590 



6?6 



INDEX 



Tibia and Fibula : 

lower end, internal malleolus 
isolated, 594 

etiology, 594 
prognosis, 595 
symptoms, 594 
treatment, 595 
malleolar, Pott's, 5/8 
displacements, 580 
etiology, 578 
mechanism, 580 
prognosis, 584 
results, 587 
symptoms, 581 
treatment, 584 
Pott's, inverted, 591 
etiology, 591 
mechanism, 591 
prognosis, 59.3 
symptoms, 591 
treatment, 593 
supramalleolar, 575 
diagnosis, 576 
etiology, 576 
prognosis, 576 
statistics, 575 
symptoms, 576 
treatment, 576 
tibia, anterior articular edge, 596 
etiology, 596 
symptoms, 596 
treatment, 595 
shaft, 555 
complications, 562 
displacements, 559 
etiology, 555 
prognosis. 562 
results, 572 
statistics, 555 
symptoms, 561 
treatment, 563 

non-operative, 564 
operative. 565 
open fractures, 568 
upper end, 543 
complications, 551 
etiology. 548 
prognosis, 550 
symptoms. 544 
adults. 544 
children, 550 
treatment, 551 
varieties, 543 
treatment, summary of, 598 
lower end, 598 
shaft. 598 
upper end, 598 
Tibia, shaft of, isolated of, 573 
etiology, 573 
statistics, 573 
symptoms, 573 
treatment, 573 
Traction, longitudinal, in marked abduc- 
tion in fractures of neck of femur, 477 
Traumatic asphyxia in rib fractures, 261 



Treatment, ambulatory, of fractures, 83 
functional, of fractures, 82 
general considerations, 56 
operative, cases designated for, 87 
Albee's inlay bone graft, 109 
instruments used, no 
technic, 1 1 1 
American Surgical Association, 
quoted; conclusions in the, 114, 
ll 5 
cause of failures of, quoted from 
cal Association, fracture com- 
mittee, quoted, 114 
cause of failures of. quoted from 
fracture committee of the B. M. 
A., 114 
Treatment, operative, conclusions of 
American Surgical Association, 
quoted, 114, 115 
contraindications to, 87 
importance of external splinting, 

109 
indications that call for, 88 
of closed fractures. 85 
time of operation. 89 

in recent closed fractures. 89 
in fractures impossible of reten- 
tion, 89 
in non-union, deficient union, or 
faulty union, 90 
technic of operation in closed frac- 
tures, 91 
repair without internal fixation, 

93 
repair with internal fixation, 93 
Trophic and vasomotor disturbances in 
vertebral fractures, 236 

Union, delayed, 26 

vicious, 27 

non-, 27 
Uterine fractures, 10 

Varieties of fractures, n 

in relation to condition of surround- 
ing soft parts, 11 
in relation to degree, ir 
in relation to direction and character 

of lines of fracture, 12 
in relation to epiphyseal lines, 15 
in relation to neighboring joints, 14 
in relation to number of fragments, 

15 
in relation to position of the frac- 
ture, 14 
Velpeau dressing for fractures of clavi- 
cle, 275 
Venesection, in fractures of skull, 160 
Vertebrae, 212 
anatomy, 212 
diagnosis, 243 
etiology, 215 
prognosis, 244 
statistics, 214, 244 
surface markings, 214 



INDEX 



677 



Vertebrae, symptoms, 

those associated with the fracture, 

225 
those due to injury to spinal cord 

and nerve roots, 227 
posture in bed, 227 
paralysis, motor, 228 
paralysis, sensory, 230 
reflex disturbances, 233 
trophic and vasomotor disturb- 
ances, 236 
lesions of various segments, 238 
hemorrhage in dura and spinal 
cord, 242 
treatment, 

non-operative, 246 

in absence of injury to spinal 

cord, 246 
in presence of injury to spinal 

cord, 246 
care of bladder and rectum, 247 
operative, 247 
indications, contraindications, 

247 
lammectomy, technic, 248 
postoperative, 250 
varieties, 216 
Vertebrae, fractures, disturbances of re- 
flexes governing bladder and rec- 
tum, 235 
mortality in fractures of, Oliver, 

J. C, quoted, 245 
mortality, operative, in fractures of, 

Lloyd, Samuel, quoted, 245 
operative mortality in fractures of, 

Thornburn, quoted, 245 
statistics on fractures of, Menard, 
quoted, 214 
Vertebral fractures, mortality in, Burrell, 
quoted, 244 
mortality in, Chipault, quoted, 245 
Vicious union, 27 



Volkmann's contracture, 31, 32 

(See ischaemic-muscular atrophy) 
Volkmann's ischaemic contracture, 338 
etiology, 338 
pathology, 338 
symptoms, 339 
treatment, 340 
Vogt's rule, for trephining points in mid- 
dle meningeal hemorrhage, 166 

Wagner, quoted ; mortality of skull frac- 
tures, 158 

Weight-bearing after fractures of tibia 
and fibula, 565 

Wendt, quoted ; statistics on supracon- 
dylar fractures of humerus, 322 

Whitman's method of abduction in the 
treatment of separation of the upper 
femoral epiphysis, 482 

Whitman's method of abduction in frac- 
ture of neck of femur, 477 
principles and mode of application, 
.478 

Wiesmann, quoted ; operative mortality 
in middle meningeal hemorrhage, 167 

Wood-Jones, quoted ; type of fractures 
of vertebrae in judicial hanging, 223 

Wright, Almroth, quoted ; use of hyper- 
tonic sodium citrate solution, in gun- 
shot injuries, 660 

Wrist-drop, musculospiral nerve injury 
complicating fracture of shaft of 
humerus, 314 

Wyeth's method of suture for fracture 
of patella, 535 

Zuppinger's apparatus in the treatment 

of fractures of tibia and fibula, 565 
Zuppinger's method of extension, 78 
principles of method, 78 
disadvantages of method, 79 
Zuppinger's modified method in the treat- 
ment of subtrochanteric fractures, 489 



IUhSLSE! CONGRESS 



021 067 544 9 



